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Fleurent-Grégoire C, Burgess N, Denehy L, Edbrooke L, Engel D, Testa GD, Fiore JF, McIsaac DI, Chevalier S, Moore J, Grocott MP, Copeland R, Levett D, Scheede-Bergdahl C, Gillis C. Outcomes reported in randomised trials of surgical prehabilitation: a scoping review. Br J Anaesth 2024; 133:42-57. [PMID: 38570300 DOI: 10.1016/j.bja.2024.01.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/09/2024] [Accepted: 01/29/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation. METHODS MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework. RESULTS We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein. CONCLUSIONS There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.
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Affiliation(s)
- Chloé Fleurent-Grégoire
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Research Institute of the McGill University Health Centre, Montreal, QC, Canada
| | - Nicola Burgess
- Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia; Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Lara Edbrooke
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, Melbourne, VIC, Australia; Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Stéphanie Chevalier
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Research Institute of the McGill University Health Centre, Montreal, QC, Canada; Department of Medicine, McGill University, Montreal, QC, Canada
| | - John Moore
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - Michael P Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton - University of Southampton, Southampton, UK
| | - Robert Copeland
- Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield, UK
| | - Denny Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton - University of Southampton, Southampton, UK
| | - Celena Scheede-Bergdahl
- Department of Kinesiology and Physical Education, McGill Research, Centre for Physical Activity & Health, McGill University, Montreal, QC, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montreal, QC, Canada; Department of Surgery, McGill University, Montreal, QC, Canada; Department of Anesthesia, McGill University, Montreal, QC, Canada.
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2
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Del Bianco N, Borsati A, Toniolo L, Ciurnielli C, Belluomini L, Insolda J, Sposito M, Milella M, Schena F, Pilotto S, Avancini A. What is the role of physical exercise in the era of cancer prehabilitation? A systematic review. Crit Rev Oncol Hematol 2024; 198:104350. [PMID: 38642726 DOI: 10.1016/j.critrevonc.2024.104350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 03/18/2024] [Accepted: 04/10/2024] [Indexed: 04/22/2024] Open
Abstract
PURPOSE Exercise before surgery, as part of prehabilitation, aiming to enhance patients' functional and physiological capacity, has become widespread, necessitating an in-depth understanding. METHODS A systematic search was conducted on Pubmed, Cochrane, and Scopus to examine the effect of exercise as prehabilitation, alone or in combination with other interventions, in patients with cancer. Interventional studies applying a single-arm, randomized controlled, or nonrandomized design were included. RESULTS A total of 96 studies were included, and categorized according to cancer types, i.e., gynecological, breast, urological, gastrointestinal and lung cancer. For each cancer site, the effect of exercise, on physical fitness parameters and postoperative outcomes, including length of hospital stay and postoperative complications, was reported. CONCLUSION Exercise as prehabilitation may have an important role in improving physical fitness, postoperative outcomes, and accelerating recovery, especially in certain types of malignancies.
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Affiliation(s)
- Nicole Del Bianco
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Anita Borsati
- Department of Medicine, Verona University Hospital Trust, Verona, Italy
| | - Linda Toniolo
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Christian Ciurnielli
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Lorenzo Belluomini
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona, Verona, Italy
| | - Jessica Insolda
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona, Verona, Italy
| | - Marco Sposito
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona, Verona, Italy
| | - Michele Milella
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona, Verona, Italy
| | - Federico Schena
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sara Pilotto
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona, Verona, Italy.
| | - Alice Avancini
- Section of Oncology, Department of Engineering for Innovation Medicine, University of Verona, Verona, Italy
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3
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Fleurent-Grégoire C, Burgess N, McIsaac DI, Chevalier S, Fiore JF, Carli F, Levett D, Moore J, Grocott MP, Copeland R, Edbrooke L, Engel D, Testa GD, Denehy L, Gillis C. Towards a common definition of surgical prehabilitation: a scoping review of randomised trials. Br J Anaesth 2024:S0007-0912(24)00182-X. [PMID: 38677949 DOI: 10.1016/j.bja.2024.02.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 01/29/2024] [Accepted: 02/26/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition. METHODS The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis. RESULTS We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.' CONCLUSIONS A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.
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Affiliation(s)
- Chloé Fleurent-Grégoire
- School of Human Nutrition, McGill University, Montréal, QC, Canada; Research Institute of the McGill University Health Centre, Montréal, QC, Canada
| | - Nicola Burgess
- Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Stéphanie Chevalier
- School of Human Nutrition, McGill University, Montréal, QC, Canada; Research Institute of the McGill University Health Centre, Montréal, QC, Canada; Department of Medicine, McGill University, Montréal, QC, Canada
| | - Julio F Fiore
- Department of Surgery, McGill University, Montréal, QC, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montréal, QC, Canada
| | - Denny Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton-University of Southampton, Southampton, UK
| | - John Moore
- Department of Anaesthesia, Manchester University NHS Foundation Trust, Manchester, UK
| | - Michael P Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton-University of Southampton, Southampton, UK
| | - Robert Copeland
- Advanced Wellbeing Research Centre, Sheffield Hallam University, Sheffield UK
| | - Lara Edbrooke
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, VIC, Australia; Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Giuseppe Dario Testa
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Linda Denehy
- Department of Physiotherapy, Melbourne School of Health Sciences, University of Melbourne, VIC, Australia; Department of Health Services Research, The Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Montréal, QC, Canada; Department of Surgery, McGill University, Montréal, QC, Canada; Department of Anesthesia, McGill University, Montréal, QC, Canada.
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4
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Ricci C, Alberici L, Serbassi F, Caraceni P, Domenicali M, Ingaldi C, Grego DG, Mazzucchelli C, Casadei R. Physical Prehabilitation in Patients who Underwent Major Abdominal Surgery: A Comprehensive Systematic Review and Component Network Meta-Analysis Using GRADE and CINeMA Approach. Ann Surg Oncol 2024; 31:1725-1738. [PMID: 38038791 PMCID: PMC10838229 DOI: 10.1245/s10434-023-14632-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/03/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Physical prehabilitation is recommended before major abdominal surgery to ameliorate short-term outcomes. METHODS A frequentist, random-effects network meta-analysis (NMA) was performed to clarify which type of preoperative physical activity among aerobic exercise (AE), inspiratory muscle training (IMT), and resistance training produces benefits in patients who underwent major abdominal surgery. The surface under the P-score, odds ratio (OR), or mean difference (MD) with a 95% confidence interval (CI) were reported. The results were adjusted by using the component network approach. The critical endpoints were overall and major morbidity rate and mortality rate. The important but not critical endpoints were the length of stay (LOS) and pneumonia. RESULTS The meta-analysis included 25 studies. The best approaches for overall morbidity rate were AE and AE + IMT (OR = 0.61, p-score = 0.76, and OR = 0.66, p-score = 0.68). The best approaches for pneumonia were AE + IMT and AE (OR = 0.21, p-score = 0.91, and OR = 0.52, p-score = 0.68). The component analysis confirmed that the best incremental OR (0.30; 95% CI 0.12-0.74) could be obtained using AE + IMT. The best approach for LOS was AE alone (MD - 1.63 days; 95% CI - 3.43 to 0.18). The best combination of components was AE + IMT (MD - 1.70; 95% CI - 2.06 to - 1.27). CONCLUSIONS Physical prehabilitation reduces the overall morbidity rate, pneumonia, and length of stay. The most relevant effect of prehabilitation requires the simultaneous use of AE and IMT.
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Affiliation(s)
- Claudio Ricci
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy.
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy.
| | - Laura Alberici
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
| | - Francesco Serbassi
- Alma Mater Studiorum, Biology of the Health Faculty, University of Bologna, Bologna, Italy
| | - Paolo Caraceni
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
| | - Marco Domenicali
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, AUSL Romagna, "S. Maria Delle Croci" Hospital, Ravenna, Italy
| | - Carlo Ingaldi
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
| | - Davide Giovanni Grego
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
- Alma Mater Studiorum, Biology of the Health Faculty, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy
- Department of Primary Health Care, Internal Medicine Unit Addressed to Frailty and Aging, AUSL Romagna, "S. Maria Delle Croci" Hospital, Ravenna, Italy
| | - Carlo Mazzucchelli
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
| | - Riccardo Casadei
- Division of Pancreatic Surgery, IRCCS Azienda Ospedaliero-Universitaria Di Bologna, via Albertoni 15, Bologna, Italy
- Department of Internal Medicine and Surgery (DIMEC), Alma Mater Studiorum, University of Bologna, Bologna, Italy
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5
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Yaceczko S, Baltz J. Evaluation of nutrition components within prehabilitation programs in gastrointestinal cancers: Is prehab worth the hype? Nutr Clin Pract 2024; 39:117-128. [PMID: 37772471 DOI: 10.1002/ncp.11079] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/01/2023] [Accepted: 08/27/2023] [Indexed: 09/30/2023] Open
Abstract
Nutrition impact symptoms and unintended weight loss are prevalent in patients with gastrointestinal cancers, especially during the perioperative period or while prescribed anticancer treatments. Because patients may experience loss of lean body mass and malnutrition, aggressive nutrition intervention prior to surgery should be considered. Cancer prehabilitation is a process spanning the care continuum from diagnosis to the time of surgery encompassing nutrition support, psychological and physical assessment, and targeted interventions. Thirteen studies published between 2013 and 2023 were included in this review and evaluated prehabilitation programs' impact on postoperative outcomes in patients with gastrointestinal cancers. Literature continues to emerge supporting the integration of nutrition into a prehabilitation program because of its potential to contribute to improved clinical outcomes, quality of life, and cost-effectiveness, but considerable variation exists with respect to the specific recommendations provided by current prehabilitation programs.
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Affiliation(s)
- Shelby Yaceczko
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Jami Baltz
- Stanford Health Care, Comprehensive Cancer Center, Stanford, California, USA
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6
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Mylius CF, Mooiweer Y, Krijnen WP, Takken T, van Munster BC, van der Schans CP, Klaase JM. Changes in Self-Reported and Device-Measured Physical Activity Before Abdominal Resection Surgery: A Meta-Analysis. Clin Rehabil 2024; 38:216-233. [PMID: 37731348 DOI: 10.1177/02692155231202215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVE To determine the effect of interventions on physical activity levels of patients awaiting abdominal resection surgery using self-reported as well as device-measured outcome measures. DATA SOURCE PubMed and EMBASE databases were searched on the 18th of April 2023 up to April 2023 for studies on interventions to promote physical activity during the preoperative phase. REVIEW METHODS Studies were included if pre- and post-intervention physical activity was measured between diagnosis and abdominal surgery. Risk of bias was assessed by the Physiotherapy Evidence Database (PEDro) assessment tool for trials. Meta-analyses were performed to assess the effect of the pre-surgery activity promoting interventions on self-reported and device-measured physical activity. RESULTS Seventeen studies were included in the analysis with 452 subjects in the intervention groups. The random-effect meta-analysis showed a moderate improvement in intervention groups measures in pre-surgery physical activity levels compared to the baseline (SMD = 0.67, [CI = 0.30;1.03], I2 = 79%). The self-reported subgroup meta-analysis showed the largest increase in performed physical activity, (SMD = 0.78, [CI = 0.4;1.15], I2 = 79%) whilst non-significant increase was shown in the device-measured subgroup (SMD = 0.16, [CI = -0.64;0.97], I2 = 58%). CONCLUSION Increasing physical activity in the preoperative phase is feasible. Self-reported physical activity outcome measures show larger effects compared to device-measured outcome measures. More high-quality research should be performed utilizing objective measures.
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Affiliation(s)
- Caspar F Mylius
- Healthy Aging, Allied Health Care and Nursing, Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen, The Netherlands
- Physiotherapy, Centre of Expertise Primary Care Groningen, Groningen, The Netherlands
| | - Yvet Mooiweer
- Center for Human Movement Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wim P Krijnen
- Healthy Aging, Allied Health Care and Nursing, Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen, The Netherlands
| | - Tim Takken
- Child Development and Exercise Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Barbara C van Munster
- University Center for Geriatric Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cees P van der Schans
- Healthy Aging, Allied Health Care and Nursing, Hanze University of Applied Sciences, Research Group Healthy Ageing, Allied Health Care and Nursing, Groningen, The Netherlands
- Department of Rehabilitation Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Health Psychology Research, University of Groningen, University Medical Center Groningen, Health Psychology Research, Groningen, The Netherlands
| | - Joost M Klaase
- Department of Hepatobiliary Surgery and Liver Transplantation, University Medical Centre Groningen, Groningen, The Netherlands
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7
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Strous MTA, Molenaar CJL, Franssen RFW, van Osch F, Belgers E, Bloemen JG, Slooter GD, Melenhorst J, Heemskerk J, de Bruïne AP, Janssen-Heijnen MLG, Vogelaar FJ. Treatment interval in curative treatment of colon cancer, does it impact (cancer free) survival? A non-inferiority analysis. Br J Cancer 2024; 130:251-259. [PMID: 38087040 PMCID: PMC10803312 DOI: 10.1038/s41416-023-02505-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/22/2023] [Accepted: 11/13/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND In treatment of colon cancer, strict waiting-time targets are enforced, leaving professionals no room to lengthen treatment intervals when advisable, for instance to optimise a patient's health status by means of prehabilitation. Good quality studies supporting these targets are lacking. With this study we aim to establish whether a prolonged treatment interval is associated with a clinically relevant deterioration in overall and cancer free survival. METHODS This retrospective multicenter non-inferiority study includes all consecutive patients who underwent elective oncological resection of a biopsy-proven primary non-metastatic colon carcinoma between 2010 and 2016 in six hospitals in the Southern Netherlands. Treatment interval was defined as time between diagnosis and surgical treatment. Cut-off points for treatment interval were ≤35 days and ≤49 days. FINDINGS 3376 patients were included. Cancer recurred in 505 patients (15.0%) For cancer free survival, a treatment interval >35 days and >49 days was non-inferior to a treatment interval ≤35 days. Results for overall survival were inconclusive, but no association was found. CONCLUSION For cancer free survival, a prolonged treatment interval, even over 49 days, is non-inferior to the currently set waiting-time target of ≤35 days. Therefore, the waiting-time targets set as fundamental objective in current treatment guidelines should become directional instead of strict targets.
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Affiliation(s)
- Maud T A Strous
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands.
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
| | | | - Ruud F W Franssen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Frits van Osch
- Department of Epidemiology, VieCuri Medical Centre, Venlo, the Netherlands
| | - Eric Belgers
- Department of Surgery, Zuyderland Hospital, Heerlen, The Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Jarno Melenhorst
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jeroen Heemskerk
- Department of Surgery, Laurentius Hospital, Roermond, The Netherlands
| | | | - Maryska L G Janssen-Heijnen
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
- Department of Epidemiology, VieCuri Medical Centre, Venlo, the Netherlands
| | - F Jeroen Vogelaar
- Department of Surgery, VieCuri Medical Centre, Venlo, The Netherlands
- Department of Epidemiology, GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
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8
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Bates A, West MA, Jack S, Grocott MPW. Preparing for and Not Waiting for Surgery. Curr Oncol 2024; 31:629-648. [PMID: 38392040 PMCID: PMC10887937 DOI: 10.3390/curroncol31020046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 01/22/2024] [Accepted: 01/22/2024] [Indexed: 02/24/2024] Open
Abstract
Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.
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Affiliation(s)
- Andrew Bates
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Malcolm A. West
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Sandy Jack
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
| | - Michael P. W. Grocott
- Perioperative and Critical Care Medicine Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Southampton SO16 6YD, UK; (A.B.); (M.A.W.)
- Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK
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9
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Groen LC, van Gestel T, Daams F, van den Heuvel B, Taveirne A, Bruns ER, Schreurs HW. Community-based prehabilitation in older patients and high-risk patients undergoing colorectal cancer surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107293. [PMID: 38039905 DOI: 10.1016/j.ejso.2023.107293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/21/2023] [Accepted: 11/17/2023] [Indexed: 12/03/2023]
Abstract
INTRODUCTION Prehabilitation before colorectal cancer (CRC) surgery is promising to prevent complications and to enhance recovery, especially in patients aged 70 or older or in patients with an American Society of Anaesthesiologist (ASA) physical classification score 3-4, for whom surgery is associated with higher postoperative complications and long-lasting adverse effects on functional performance. MATERIALS AND METHODS A cohort study was conducted in a large teaching hospital in Alkmaar, the Netherlands. Fifty CRC patients (≥70 years or ASA 3-4) underwent multimodal prehabilitation between September 2020 and July 2021. The reference group comprised 50 patients (≥70 years or ASA 3-4) from a historical cohort receiving CRC surgery without prehabilitation (March 2020-August 2020). The primary outcome was 90-day postoperative complication rate. Secondary outcomes were length of stay, 90-day readmission and mortality rates and functional outcome in the prehabilitation group. RESULTS One patient in the prehabilitation group decided not to undergo surgery. Of the remaining 49 patients, 48 (98.0 %) received prehabilitation for at least 3 weeks. Of these patients, 32.7 % developed postoperative complications, compared to 58 % in the reference group (p = 0.015), and none were readmitted, in contrast to 6 reference group patients (12.0 %, p = 0.012). Length of stay and mortality did not differ significantly. Six weeks postoperatively, all functional outcomes in the prehabilitation group were significantly higher than at baseline. CONCLUSIONS Prehabilitation reduced postoperative complications and improved short-term functional outcomes in older and high-risk patients receiving CRC surgery. Further research should investigate the maintenance of long-term enhanced lifestyle and the effects of tailor-made programs.
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Affiliation(s)
- Lennaert Cb Groen
- Department of Surgery, Northwest Clinics, Alkmaar, NL, the Netherlands.
| | - Tess van Gestel
- Department of Surgery, Northwest Clinics, Alkmaar, NL, the Netherlands
| | - Freek Daams
- Department of Surgery, Academic University Medical Center, Location VU, Amsterdam, NL, the Netherlands; Cancer Center Amsterdam, Amsterdam, NL, the Netherlands
| | - Baukje van den Heuvel
- Department of Operational Theaters, Radboud University Medical Center, Nijmegen, NL, the Netherlands
| | - Ann Taveirne
- Physiotherapy for Oncology Patients, Heiloo, NL, the Netherlands
| | - Emma Rj Bruns
- Department of Surgery, Academic University Medical Center, Location VU, Amsterdam, NL, the Netherlands
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10
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Meneses-Echavez JF, Loaiza-Betancur AF, Díaz-López V, Echavarría-Rodríguez AM, Triana-Reina HR. Prehabilitation programs for individuals with cancer: a systematic review of randomized-controlled trials. Syst Rev 2023; 12:219. [PMID: 37978411 PMCID: PMC10655304 DOI: 10.1186/s13643-023-02373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/24/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Prehabilitation programs focusing on exercise training as the main component are known as a promising alternative for improving patients' outcomes before cancer surgery. This systematic review determined the benefits and harms of prehabilitation programs compared with usual care for individuals with cancer. METHODS We searched CENTRAL, MEDLINE, and EMBASE from inception to June 2022, and hand searched clinical trial registries. We included randomized-controlled trials (RCTs) in adults, survivors of any type of cancer, that compared prehabilitation programs that had exercise training as the major component with usual care or other active interventions. Outcome measures were health-related quality of life (HRQL), muscular strength, postoperative complications, average length of stay (ALOS), handgrip strength, and physical activity levels. Two reviewers independently screened the studies, extracted data, and assessed the risk of bias and the certainty of the evidence. RESULTS Twenty-five RCTs (2682 participants) published between 2010 and 2022 met our inclusion criteria. Colorectal and lung cancers were the most common diagnoses. The studies had methodological concerns regarding outcome measurement, selective reporting, and attrition. Five prehabilitation programs were compared to usual care (rehabilitation): combined training, aerobic training, respiratory muscle training plus aerobic training, respiratory muscle training plus resistance training, and pelvic floor training. The studies provided no clear evidence of an effect between groups. We assessed the overall certainty of the evidence as very low, downgraded due to serious study limitations and imprecision. CONCLUSION Prehabilitation programs focusing on exercise training may have an effect on adults with cancer, but the evidence is very uncertain. We have very little confidence in the results and the true effect is likely to be substantially different from these. Further research is needed before we can draw a more certain conclusion. SYSTEMATIC REVIEW REGISTRATION CRD42019125658.
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Affiliation(s)
- Jose F Meneses-Echavez
- Division for Health Services, Norwegian Institute of Public Health, Sandakerveien 24C, Building D11, Oslo, Norway.
- Facultad de Cultura Física, Deporte y Recreación. GICAEDS, Universidad Santo Tomás, Bogotá, Colombia.
| | - Andrés F Loaiza-Betancur
- Universidad de Antioquia. Instituto Universitario de Educación Física, Medellín, Colombia
- Grupo de Investigación en Entrenamiento Deportivo y Actividad Física Para La Salud (GIEDAF), Universidad Santo Tomás, Tunja, Colombia
| | - Víctor Díaz-López
- Universidad de Antioquia. Instituto Universitario de Educación Física, Medellín, Colombia
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11
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Triguero-Cánovas D, López-Rodríguez-Arias F, Gómez-Martínez M, Sánchez-Guillén L, Peris-Castelló F, Alcaide-Quirós MJ, Morillas-Blasco P, Arroyo A, Ramírez JM. Home-based prehabilitation improves physical conditions measured by ergospirometry and 6MWT in colorectal cancer patients: a randomized controlled pilot study. Support Care Cancer 2023; 31:673. [PMID: 37930478 DOI: 10.1007/s00520-023-08140-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
PURPOSE/BACKGROUND Prehabilitation aims to improve physical condition in the preoperative period and, therefore, decrease the loss of cardiopulmonary capacity postoperatively, with the aim of reducing complications and promoting an early recovery. This study aims to evaluate the impact of home-based prehabilitation on the physical condition of patients treated surgically for colorectal cancer. METHODS A prospective and randomized clinical study was conducted on 60 patients during two periods from October 2018 to February 2019 and from September 2019 to September 2020, in a single university hospital. Patients were randomized into two study groups (30 per group): prehabilitation vs. standard care. Changes in physical condition, measured at diagnosis, the day before surgery, and at 6-8 weeks after surgery using the cardiopulmonary exercise testing (CPET) and the 6-minute walk test (6MWT) were evaluated. RESULTS Prehabilitation reduced postoperative complications (17.4% vs. 33.3%, p = 0.22) and hospital stay (5.74 vs. 6.67 days, p = 0.30). 6MWT showed a significant improvement in the prehabilitation group (+78.9 m). Six weeks after surgery, prehabilitation showed a significant improvement in the 6MWT (+68.9 m vs. -27.2 m, p = 0.01). Significant differences were also observed in the ergospirometry between the diagnosis and postoperative study (+0.79 METs vs. -0.84 METs, p = 0.001). A strong correlation was observed between CPET and 6MWT (0.767 (p < 0.001)). CONCLUSION Home prehabilitation achieved lower overall postoperative complications than standard care and reached significant improvements in 6MWT and CET. A strong correlation was observed between CET and 6MWT, which allows validation of 6MWT as a valid and reliable measure of functional exercise capacity in colorectal patients when other, more specific and expensive tests are not available. TRIAL REGISTRATION Registered in ClinicalTrials.gov in August 2018 with registration number https://clinicaltrials.gov/study/NCT03618329?cond=Prehabilitation%20cancer&term=arroyo&distance=50&rank=1 (NCT03618329). Initial results published in Supportive Care in Cancer: Effect of home-based prehabilitation in an enhanced recovery after surgery program for patients undergoing colorectal cancer surgery during the COVID-19 pandemic. DOI: https://doi.org/10.1007/s00520-021-06343-1 .
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Affiliation(s)
- Daniel Triguero-Cánovas
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Francisco López-Rodríguez-Arias
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Manuel Gómez-Martínez
- Department of Cardiology, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Luis Sánchez-Guillén
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain.
| | - Franc Peris-Castelló
- Department of Cardiology, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - María José Alcaide-Quirós
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Pedro Morillas-Blasco
- Department of Cardiology, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Antonio Arroyo
- Department of General Surgery, Colorectal Unit, Elche University Hospital, University Miguel Hernández of Elche, Alicante, Spain
| | - Jose Manuel Ramírez
- Department of General Surgery, Colorectal Unit, University Hospital Lozano Blesa, University of Zaragoza, Zaragoza, Spain
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12
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Kinsey D, Febrey S, Briscoe S, Kneale D, Thompson Coon J, Carrieri D, Lovegrove C, McGrath J, Hemsley A, Melendez-Torres GJ, Shaw L, Nunns M. Impact of interventions to improve recovery of older adults following planned hospital admission on quality-of-life following discharge: linked-evidence synthesis. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2023; 11:1-164. [PMID: 38140881 DOI: 10.3310/ghty5117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Objectives To understand the impact of multicomponent interventions to improve recovery of older adults following planned hospital treatment, we conducted two systematic reviews, one of quantitative and one of qualitative evidence, and an overarching synthesis. These aimed to: • understand the effect of multicomponent interventions which aim to enhance recovery and/or reduce length of stay on patient-reported outcomes and health and social care utilisation • understand the experiences of patients, carers and staff involved in the delivery of interventions • understand how different aspects of the content and delivery of interventions may influence patient outcomes. Review methods We searched bibliographic databases including MEDLINE ALL, Embase and the Health Management Information Consortium, CENTRAL, and Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database, conducted forward and backward citation searching and examined reference lists of topically similar qualitative reviews. Bibliographic database searches were completed in May/June 2021 and updated in April 2022. We sought primary research from high-income countries regarding hospital inpatients with a mean/median age of minimum 60 years, undergoing planned surgery. Patients experienced any multicomponent hospital-based intervention to reduce length of stay or improve recovery. Quantitative outcomes included length of stay and any patient-reported outcome or experience or service utilisation measure. Qualitative research focused on the experiences of patients, carers/family and staff of interventions received. Quality appraisal was undertaken using the Effective Public Health Practice Project Quality Assessment Tool or an adapted version of the Wallace checklist. We used random-effects meta-analysis to synthesise quantitative data where appropriate, meta-ethnography for qualitative studies and qualitative comparative analysis for the overarching synthesis. Results Quantitative review: Included 125 papers. Forty-nine studies met criteria for further synthesis. Enhanced recovery protocols resulted in improvements to length of stay, without detriment to other outcomes, with minimal improvement in patient-reported outcome measures for patients admitted for lower-limb or colorectal surgery. Qualitative review: Included 43 papers, 35 of which were prioritised for synthesis. We identified six themes: 'Home as preferred environment for recovery', 'Feeling safe', 'Individualisation of structured programme', 'Taking responsibility', 'Essential care at home' and 'Outcomes'. Overarching synthesis: Intervention components which trigger successful interventions represent individualised approaches that allow patients to understand their treatment, ask questions and build supportive relationships and strategies to help patients monitor their progress and challenge themselves through early mobilisation. Discussion Interventions to reduce hospital length of stay for older adults following planned surgery are effective, without detriment to other patient outcomes. Findings highlight the need to reconsider how to evaluate patient recovery from the perspective of the patient. Trials did not routinely evaluate patient mid- to long-term outcomes. Furthermore, when they did evaluate patient outcomes, reporting is often incomplete or conducted using a narrow range of patient-reported outcome measures or limited through asking the wrong people the wrong questions, with lack of longer-term evaluation. Findings from the qualitative and overarching synthesis will inform policy-making regarding commissioning and delivering services to support patients, carers and families before, during and after planned admission to hospital. Study registration This trial is registered as PROSPERO registration number CRD42021230620. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 130576) and is published in full in Health and Social Care Delivery Research; Vol. 11, No. 23. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Debbie Kinsey
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Samantha Febrey
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Simon Briscoe
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Dylan Kneale
- EPPI-Centre, UCL Social Research Institute, University College London, London, UK
| | - Jo Thompson Coon
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Daniele Carrieri
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Christopher Lovegrove
- School of Health Professions, Faculty of Health and Human Sciences, University of Plymouth, Plymouth, UK
| | - John McGrath
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Anthony Hemsley
- Department of Healthcare for Older People, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | | | - Liz Shaw
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
| | - Michael Nunns
- Faculty of Health and Life Sciences, University of Exeter, Exeter, UK
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13
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Estrada DML, de Queiroz FL, Guerra LI, França-Neto PR, Lacerda-Filho A, de Miranda Silvestre SC, Coelho JM. Comparative study using propensity score matching analysis in patients undergoing surgery for colorectal cancer with or without multimodal prehabilitation. Int J Colorectal Dis 2023; 38:256. [PMID: 37878018 DOI: 10.1007/s00384-023-04547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/14/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION The complication rate after major abdominal surgery is from 35 to 50%. The multimodal prehabilitation covers all the pre-operative problems to guarantee a faster recovery and reduce the rate of morbidity and mortality after a colorectal procedure. METHODS Observational study, in patients with CRC who underwent surgical treatment between November 2020 and September 2022. The data of the patients were placed in 2 groups: prehabilitation group (PPH) and no prehabilitation group (NPPH). Demographic data, type of cancer, operative data, and postoperative data were collected. Characteristics between the groups were compared after a propensity score matching (PSM) analysis for the detection of differences. RESULTS After the PSM analysis, 46 patients were in PPH, and 63 patients were in NPPH. There was no significant difference in postoperative complications (p = 0.192). The median of comprehensive complication index (CCI) was 0 (p = 0.552). Patients in the NPPH had more hospital readmissions (p = 0.273) and more emergency room visits (p = 0.092). Multivariate log binomial regression adjusted for complications showed that pre-habilitation reduces the risk of a pos-operative complication (OR: 0.659, 95%CI, 0.434-1.00, p = 0.019). CONCLUSIONS The postoperative complication rate and LOS were similar between patients who receive operative multimodal prehabilitation for CRC surgery and those who did not. Prehabilitation was associated with reduced risk of postoperative complication after multivariate log binomial regression adjusted for complications. Patients who underwent prehabilitation had a slightly lower tendency for postoperative ER visits and hospital readmissions.
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Affiliation(s)
- Daniel Mauricio Londoño Estrada
- Department of Colorectal Surgery, Felicio Rocho Hospital, Av. do Contorno 9530-Barro Preto, Rua Tenente Brito Melo 496, Belo Horizonte, MG, CEP 30180070, Brazil.
| | - Fábio Lopes de Queiroz
- Department of Colorectal Surgery, Felicio Rocho Hospital, Av. do Contorno 9530-Barro Preto, Rua Tenente Brito Melo 496, Belo Horizonte, MG, CEP 30180070, Brazil
| | - Luiza Iannotta Guerra
- Department of Colorectal Surgery, Felicio Rocho Hospital, Av. do Contorno 9530-Barro Preto, Rua Tenente Brito Melo 496, Belo Horizonte, MG, CEP 30180070, Brazil
| | - Paulo Rocha França-Neto
- Department of Colorectal Surgery, Felicio Rocho Hospital, Av. do Contorno 9530-Barro Preto, Rua Tenente Brito Melo 496, Belo Horizonte, MG, CEP 30180070, Brazil
| | - Antônio Lacerda-Filho
- Department of Colorectal Surgery, Felicio Rocho Hospital, Av. do Contorno 9530-Barro Preto, Rua Tenente Brito Melo 496, Belo Horizonte, MG, CEP 30180070, Brazil
- Department of Surgery, Federal University of Minas Gerais School of Medicine, Av. Prof. Alfredo Balena, 190-Santa Efigênia, Belo Horizonte, Brazil
| | | | - Jose Marcos Coelho
- Department of Anesthesiology, Felicio Rocho Hospital, Av. do Contorno, 9530-Barro Preto, Belo Horizonte, Brazil
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14
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Kovoor JG, Nann SD, Barot DD, Garg D, Hains L, Stretton B, Ovenden CD, Bacchi S, Chan E, Gupta AK, Hugh TJ. Prehabilitation for general surgery: a systematic review of randomized controlled trials. ANZ J Surg 2023; 93:2411-2425. [PMID: 37675939 DOI: 10.1111/ans.18684] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/23/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Prehabilitation seeks to optimize patient health before surgery to improve outcomes. Randomized controlled trials (RCTs) have been conducted on prehabilitation, however an updated synthesis of this evidence is required across General Surgery to inform potential Supplementary discipline-level protocols. Accordingly, this systematic review of RCTs aimed to evaluate the use of prehabilitation interventions across the discipline of General Surgery. METHODS This study was registered with PROSPERO (CRD42023403289), and adhered to PRISMA 2020 and SWiM guidelines. PubMed/MEDLINE and Ovid Embase were searched to 4 March 2023 for RCTs evaluating prehabilitation interventions within the discipline of General Surgery. After data extraction, risk of bias was assessed using the Cochrane RoB 2 tool. Quantitative and qualitative data were synthesized and analysed. However, meta-analysis was precluded due to heterogeneity across included studies. RESULTS From 929 records, 36 RCTs of mostly low risk of bias were included. 17 (47.2%) were from Europe, and 14 (38.9%) North America. 30 (83.3%) investigated cancer populations. 31 (86.1%) investigated physical interventions, finding no significant difference in 16 (51.6%) and significant improvement in 14 (45.2%). Nine (25%) investigated psychological interventions: six (66.7%) found significant improvement, three (33.3%) found no significant difference. Five (13.9%) investigated nutritional interventions, finding no significant difference in three (60%), and significant improvement in two (40%). CONCLUSIONS Prehabilitation interventions showed mixed levels of effectiveness, and there is insufficient RCT evidence to suggest system-level delivery across General Surgery within standardized protocols. However, given potential benefits and non-inferiority to standard care, they should be considered on a case-by-case basis.
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Affiliation(s)
- Joshua G Kovoor
- University of Sydney, Sydney, New South Wales, Australia
- Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
| | - Silas D Nann
- Health and Information, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Dwarkesh D Barot
- Health and Information, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Devanshu Garg
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Lewis Hains
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Brandon Stretton
- Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Christopher D Ovenden
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Stephen Bacchi
- Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Health and Information, Adelaide, South Australia, Australia
- University of Adelaide, Adelaide, South Australia, Australia
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Erick Chan
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Aashray K Gupta
- University of Sydney, Sydney, New South Wales, Australia
- Health and Information, Adelaide, South Australia, Australia
- Gold Coast University Hospital, Gold Coast, Queensland, Australia
- University of Adelaide, Adelaide, South Australia, Australia
| | - Thomas J Hugh
- University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, Sydney, New South Wales, Australia
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Engel D, Testa GD, McIsaac DI, Carli F, Santa Mina D, Baldini G, Scheede-Bergdahl C, Chevalier S, Edgar L, Beilstein CM, Huber M, Fiore JF, Gillis C. Reporting quality of randomized controlled trials in prehabilitation: a scoping review. Perioper Med (Lond) 2023; 12:48. [PMID: 37653530 PMCID: PMC10472732 DOI: 10.1186/s13741-023-00338-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/21/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists. METHODS Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions. SOURCES OF EVIDENCE search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane. CHARTING METHODS identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD). RESULTS We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1). CONCLUSION Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions.
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Affiliation(s)
- Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anesthesia, McGill University, Montréal, QC, Canada
| | - Giuseppe Dario Testa
- Department of Anesthesia, McGill University, Montréal, QC, Canada
- Division of Geriatric and Intensive Care Medicine, University of Florence and Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Daniel I McIsaac
- Clinical Epidemiology Program, Department of Anesthesiology and Pain Medicine, Ottawa Hospital Research Institute, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Francesco Carli
- Department of Anesthesia, McGill University, Montréal, QC, Canada
| | - Daniel Santa Mina
- Department of Anesthesia and Pain Management, Faculty of Medicine, Faculty of Kinesiology and Physical Education, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Gabriele Baldini
- Section of Anesthesiology, Intensive Care and Pain Medicine, Anesthesiology and Intensive Care Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Stéphanie Chevalier
- School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Quebec, H9X 3V9, Canada
- Department of Medicine, Research Institute of the McGill University Health Centre, McGill University, Montreal, QC, Canada
| | - Linda Edgar
- Prehabilitation Clinic, Montreal General Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Christian M Beilstein
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Julio F Fiore
- Department of Surgery, McGill University, Montreal, QC, H3G 1A4, Canada
| | - Chelsia Gillis
- Department of Anesthesia, McGill University, Montréal, QC, Canada.
- School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Quebec, H9X 3V9, Canada.
- Department of Surgery, McGill University, Montreal, QC, H3G 1A4, Canada.
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Fong M, Kaner E, Rowland M, Graham HE, McEvoy L, Hallsworth K, Cucato G, Gibney C, Nedkova M, Prentis J, Madigan CD. The effect of preoperative behaviour change interventions on pre- and post-surgery health behaviours, health outcomes, and health inequalities in adults: A systematic review and meta-analyses. PLoS One 2023; 18:e0286757. [PMID: 37406002 DOI: 10.1371/journal.pone.0286757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 05/23/2023] [Indexed: 07/07/2023] Open
Abstract
BACKGROUND Prehabilitation interventions are being delivered across surgical specialities to improve health risk behaviours leading to better surgical outcomes and potentially reduce length of hospital stay. Most previous research has focused on specific surgery specialities and has not considered the impact of interventions on health inequalities, nor whether prehabilitation improves health behaviour risk profiles beyond surgery. The aim of this review was to examine behavioural Prehabilitation interventions across surgeries to inform policy makers and commissioners of the best available evidence. METHODS AND FINDINGS A systematic review and meta-analysis of randomised controlled trials (RCTs) was conducted to determine the effect of behavioural prehabilitation interventions targeting at least one of: smoking behaviour, alcohol use, physical activity, dietary intake (including weight loss interventions) on pre- and post-surgery health behaviours, health outcomes, and health inequalities. The comparator was usual care or no treatment. MEDLINE, PubMed, PsychINFO, CINAHL, Web of Science, Google Scholar, Clinical trials and Embase databases were searched from inception to May 2021, and the MEDLINE search was updated twice, most recently in March 2023. Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tool. Outcomes were length of stay, six-minute walk test, behaviours (smoking, diet, physical activity, weight change, and alcohol), and quality of life. Sixty-seven trials were included; 49 interventions targeted a single behaviour and 18 targeted multiple behaviours. No trials examined effects by equality measures. Length of stay in the intervention group was 1.5 days shorter than the comparator (n = 9 trials, 95% CI -2.6 to -0.4, p = 0.01, I2 83%), although in sensitivity analysis prehabilitation had the most impact in lung cancer patients (-3.5 days). Pre-surgery, there was a mean difference of 31.8 m in the six-minute walk test favouring the prehabilitation group (n = 19 trials, 95% CI 21.2 to 42.4m, I2 55%, P <0.001) and this was sustained to 4-weeks post-surgery (n = 9 trials, mean difference = 34.4m (95%CI 12.8 to 56.0, I2 72%, P = 0.002)). Smoking cessation was greater in the prehabilitation group before surgery (RR 2.9, 95% CI 1.7 to 4.8, I2 84%), and this was sustained at 12 months post-surgery (RR 1.74 (95% CI 1.20 to 2.55, I2 43%, Tau2 0.09, p = 0.004)There was no difference in pre-surgery quality of life (n = 12 trials) or BMI (n = 4 trials). CONCLUSIONS Behavioural prehabilitation interventions reduced length of stay by 1.5 days, although in sensitivity analysis the difference was only found for Prehabilitation interventions for lung cancer. Prehabilitation can improve functional capacity and smoking outcomes just before surgery. That improvements in smoking outcomes were sustained at 12-months post-surgery suggests that the surgical encounter holds promise as a teachable moment for longer-term behavioural change. Given the paucity of data on the effects on other behavioural risk factors, more research grounded in behavioural science and with longer-term follow-up is needed to further investigate this potential.
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Affiliation(s)
- Mackenzie Fong
- NIHR Applied Research Collaboration, North East and North Cumbria, United Kingdom
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Eileen Kaner
- NIHR Applied Research Collaboration, North East and North Cumbria, United Kingdom
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Maisie Rowland
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Henrietta E Graham
- Centre for Lifestyle Medicine and Behaviour (CLiMB), The School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
| | - Louise McEvoy
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Kate Hallsworth
- NIHR Newcastle BRC, Newcastle upon Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Gabriel Cucato
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, United Kingdom
| | - Carla Gibney
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Martina Nedkova
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - James Prentis
- Department of Perioperative and Critical Care Medicine, Freeman Hospital, Newcastle Upon Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom
| | - Claire D Madigan
- Centre for Lifestyle Medicine and Behaviour (CLiMB), The School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, United Kingdom
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17
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Efficacy of supervised exercise prehabilitation programs to improve major abdominal surgery outcomes: A systematic review and meta-analysis. J Clin Anesth 2023; 86:111053. [PMID: 36736208 DOI: 10.1016/j.jclinane.2023.111053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/15/2022] [Accepted: 01/08/2023] [Indexed: 02/04/2023]
Abstract
The optimal package of components for a prehabilitation intervention remains unclear. The aim was to determine the efficacy of supervised exercise prehabilitation programs to enhance patient fitness and improve surgical outcomes. The protocol was preregistered (PROSPERO: CRD42020180693). PubMed, MEDLINE, CINAHL, AMED, CENTRAL, PeDro, ClinicalTrials.gov and the WHO International Clinical Trials Registry were searched. Randomized controlled trials (RCTs) of supervised prehabilitation programs before major abdominal surgery were included. Physical function, cardiorespiratory capacity and surgical outcomes were the primary outcomes measures. Risk of bias was assessed according to the Cochrane Risk of Bias 1.0 tool for RCTs. Data are summarized narratively, and where possible, quantitavely. Meta-analyses results are reported as risk ratios (RR), mean difference of changes between baseline and follow-up time points or mean difference between groups and 95% confidence interval (CI). Twenty RCTs were included in the analysis with a total of 1258 patients. The average 6-min walking distance change was +33 m in the prehabilitation group compared to the usual care (UC) group after prehabilitation (95% CI: [13, 53], P < 0.01). Only in studies with more than one supervised session per week changes in 6-min-walk distance were significantly higher in the prehabilitation group compared to the UC group after prehabiliatation (Mean difference: 47 m, 95% [CI]: [20-75], P < 0.01). The change in peak volume of oxygen uptake during a maximum cardiopulmonary test was +1.47 mL·kg-1·min-1 in the prehabilitation group compared to the UC group (95% CI: [0.68, 2.25], P < 0.01). There was no significant difference in the change in oxygen uptake at anaerobic threshold between groups (Mean differences: 0.47, 95% CI: [-0.16, 1.10], P:0.14). Post-operative complications incidence was similar between groups (RR: 0.80, 95% CI: [0.61, 1.05], P:0.11), irrespective of the frequency of supervised session per week (RR: 0.67, 95% CI: [0.43, 1.03], P:0.07). In conclusion, prehabilitation programmes with more than one supervised session per week improved physical function but did not enhance surgical outcomes.
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18
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Molenaar CJL, Minnella EM, Coca-Martinez M, ten Cate DWG, Regis M, Awasthi R, Martínez-Palli G, López-Baamonde M, Sebio-Garcia R, Feo CV, van Rooijen SJ, Schreinemakers JMJ, Bojesen RD, Gögenur I, van den Heuvel ER, Carli F, Slooter GD. Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg 2023; 158:572-581. [PMID: 36988937 PMCID: PMC10061316 DOI: 10.1001/jamasurg.2023.0198] [Citation(s) in RCA: 50] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 11/19/2022] [Indexed: 03/30/2023]
Abstract
Importance Colorectal surgery is associated with substantial morbidity rates and a lowered functional capacity. Optimization of the patient's condition in the weeks prior to surgery may attenuate these unfavorable sequelae. Objective To determine whether multimodal prehabilitation before colorectal cancer surgery can reduce postoperative complications and enhance functional recovery. Design, Setting, and Participants The PREHAB randomized clinical trial was an international, multicenter trial conducted in teaching hospitals with implemented enhanced recovery after surgery programs. Adult patients with nonmetastasized colorectal cancer were assessed for eligibility and randomized to either prehabilitation or standard care. Both arms received standard perioperative care. Patients were enrolled from June 2017 to December 2020, and follow-up was completed in December 2021. However, this trial was prematurely stopped due to the COVID-19 pandemic. Interventions The 4-week in-hospital supervised multimodal prehabilitation program consisted of a high-intensity exercise program 3 times per week, a nutritional intervention, psychological support, and a smoking cessation program when needed. Main Outcomes and Measures Comprehensive Complication Index (CCI) score, number of patients with CCI score more than 20, and improved walking capacity expressed as the 6-minute walking distance 4 weeks postoperatively. Results In the intention-to-treat population of 251 participants (median [IQR] age, 69 [60-76] years; 138 [55%] male), 206 (82%) had tumors located in the colon and 234 (93%) underwent laparoscopic- or robotic-assisted surgery. The number of severe complications (CCI score >20) was significantly lower favoring prehabilitation compared with standard care (21 of 123 [17.1%] vs 38 of 128 [29.7%]; odds ratio, 0.47 [95% CI, 0.26-0.87]; P = .02). Participants in prehabilitation encountered fewer medical complications (eg, respiratory) compared with participants receiving standard care (19 of 123 [15.4%] vs 35 of 128 [27.3%]; odds ratio, 0.48 [95% CI, 0.26-0.89]; P = .02). Four weeks after surgery, 6-minute walking distance did not differ significantly between groups when compared with baseline (mean difference prehabilitation vs standard care 15.6 m [95% CI, -1.4 to 32.6]; P = .07). Secondary parameters of functional capacity in the postoperative period generally favored prehabilitation compared with standard care. Conclusions and Relevance This PREHAB trial demonstrates the benefit of a multimodal prehabilitation program before colorectal cancer surgery as reflected by fewer severe and medical complications postoperatively and an optimized postoperative recovery compared with standard care. Trial Registration trialregister.nl Identifier: NTR5947.
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Affiliation(s)
| | - Enrico Maria Minnella
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | - Miquel Coca-Martinez
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
- Department of Anesthesia, Hospital Clínic de Barcelona, Barcelona, Spain
| | | | - Marta Regis
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Rashami Awasthi
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Raquel Sebio-Garcia
- Physical Medicine and Rehabilitation Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Carlo Vittorio Feo
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- Unit of Provincial General Surgery, Azienda Unità Sanitaria Locale Ferrara, Ferrara, Italy
| | | | | | - Rasmus Dahlin Bojesen
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Roskilde, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Edwin R. van den Heuvel
- Department of Mathematics and Computer Science, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Francesco Carli
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada
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19
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Khalil MT, Rathore FA. Does Prehabilitation in Colorectal Cancer Surgery Improve Functional Capacity, Quality of Life, and Reduce Postoperative Complications?: A Cochrane Review Summary With Commentary. Am J Phys Med Rehabil 2023; 102:548-549. [PMID: 36821479 DOI: 10.1097/phm.0000000000002219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
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20
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Chang MC, Choo YJ, Kim S. Effect of prehabilitation on patients with frailty undergoing colorectal cancer surgery: a systematic review and meta-analysis. Ann Surg Treat Res 2023; 104:313-324. [PMID: 37337603 PMCID: PMC10277181 DOI: 10.4174/astr.2023.104.6.313] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/25/2023] [Accepted: 04/25/2023] [Indexed: 06/21/2023] Open
Abstract
Purpose The effect of prehabilitation in patients with frailty undergoing colorectal cancer surgery remains controversial. This meta-analysis aimed to assess the impact of prehabilitation before colorectal surgery on the functional outcomes and postoperative complications in patients with frailty undergoing colorectal cancer surgery. Methods PubMed, EMBASE, Cochrane Library, and Scopus databases were searched for articles published up to November 9, 2022. We included randomized and non-randomized trials in which the effects of prehabilitation in patients with frailty undergoing colorectal cancer surgery were investigated against a control group. Data extracted for our meta-analysis included the 6-minute walk test (6MWT), postoperative incidence of complications (Clavien-Dindo classification ≥IIIa), comprehensive complication index (CCI), and length of stay (LOS) in the hospital. Results Compared with the control group, we found a significant improvement in the incidence of postoperative complications and shorter LOS in the hospital in the prehabilitation group. However, the 6MWT and CCI results showed no significant differences between the 2 groups. Conclusion Prehabilitation in patients with frailty who underwent colorectal cancer surgery improved the incidence of postoperative complications and LOS in the hospital. Hence, clinicians should consider conducting or recommending prehabilitation exercises prior to colorectal cancer surgery in patients with frailty.
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Affiliation(s)
- Min Cheol Chang
- Department of Rehabilitation Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Yoo Jin Choo
- Department of Rehabilitation Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Sohyun Kim
- Department of Surgery, Yeungnam University College of Medicine, Daegu, Korea
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21
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Molenaar CJ, van Rooijen SJ, Fokkenrood HJ, Roumen RM, Janssen L, Slooter GD. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database Syst Rev 2023; 5:CD013259. [PMID: 37162250 PMCID: PMC10171468 DOI: 10.1002/14651858.cd013259.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
BACKGROUND Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes. OBJECTIVES To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible. MAIN RESULTS We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. The effects of prehabilitation on the number of complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250), emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250) and re-admissions (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250) were small or even trivial. The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. The effects on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies. AUTHORS' CONCLUSIONS Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. A solid effect on the number of omplications, postoperative emergency department visits and re-admissions could not be established. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.
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Affiliation(s)
| | | | | | - Rudi Mh Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| | - Loes Janssen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
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22
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Boyle H, Fullbrook A, Wills A, Veal I, Peat N, Al-Noor Z, Bradshaw R, Raga A, Hegarty A, Hainsworth A, Ilyas M, Banugo P, Bidd H. Multimodal prehabilitation service for patients with colorectal cancer: the challenges of implementation. BMJ Open Qual 2023; 12:bmjoq-2022-002064. [PMID: 37220992 DOI: 10.1136/bmjoq-2022-002064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 04/25/2023] [Indexed: 05/25/2023] Open
Abstract
Prehabilitation has been shown to improve outcomes for patients undergoing major surgery; benefits include reductions in length of hospital stay and postoperative complications. Multimodal prehabilitation programmes lead to improved patient engagement and experience. This report describes implementation of a personalised multimodal prehabilitation programme for patients awaiting colorectal cancer surgery. We aim to highlight the successes, challenges and future direction of our programme.Patients listed for colorectal cancer surgery were referred for initial prehabilitation assessment. The prehabilitation group were assessed by specialist physiotherapists, dieticians and psychologists. An individualised programme was developed for each patient, aiming to optimise preoperative functional capacity and enhance physical and psychological resilience. Clinical primary outcome measures were recorded and compared with contemporaneous controls. For those undergoing prehabilitation, a set of secondary functional, nutritional and psychological outcomes were recorded at initial assessment and on completion of the programme.61 patients were enrolled in the programme from December 2021 to October 2022. 12 patients were excluded as they received less than 14 days prehabilitation or had incomplete data. The remaining 49 patients received a median duration of 24 days prehabilitation (range 15-91 days). The results show statistically significant improvements in the following functional outcome measures after prehabilitation: Rockwood scores, maximal inspiratory pressures, International Physical Activity Questionnaire Score and Functional Assessment of Chronic Illness - Fatigue Score. There was a lower postoperative complication rate in the prehabilitation group when compared with a control group (50% vs 67%).This quality improvement project has 3 Plan-Do-Study-Act (PDSA) cycles. PDSA 1 demonstrates prehabilitation can be successfully imbedded within a colorectal surgical unit and that patients are grateful for the service. PDSA 2 provides the project's first complete data set and demonstrates functional improvements in patients undergoing prehabilitation. The third PDSA cycle is ongoing and aims to refine the prehabilitation interventions and improve clinical outcomes for patients undergoing colorectal cancer surgery.
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Affiliation(s)
- Henry Boyle
- Department of Anaesthesia, Maidstone and Tunbridge Wells NHS Trust, Maidstone, UK
| | - Aidan Fullbrook
- Department of Anaesthesia, Hutt Valley District Health Board, Newtown, New Zealand
| | - Alasdair Wills
- Department of Anaesthesia, Guy's and St Thomas' Hospital Foundation NHS Trust, London, UK
| | - Isla Veal
- Department of Physiotherapy, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Nicola Peat
- Department of Physiotherapy, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Zainab Al-Noor
- Department of Clinical Psychology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Rebecca Bradshaw
- Department of Dietetics, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Arlene Raga
- Colorectal Cancer Surgery, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Aoife Hegarty
- Department of Anaesthesia, Guy's and St Thomas' Hospital Foundation NHS Trust, London, UK
| | - Alison Hainsworth
- Colorectal Cancer Surgery, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Minahi Ilyas
- Colorectal Cancer Surgery, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Pele Banugo
- Department of Anaesthesia, Guy's and St Thomas' Hospital Foundation NHS Trust, London, UK
| | - Heena Bidd
- Department of Anaesthesia, Guy's and St Thomas' Hospital Foundation NHS Trust, London, UK
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Abdelfatah E, Ramos-Santillan V, Cherkassky L, Cianchetti K, Mann G. High Risk, High Reward: Frailty in Colorectal Cancer Surgery is Associated with Worse Postoperative Outcomes but Equivalent Long-Term Oncologic Outcomes. Ann Surg Oncol 2023; 30:2035-2045. [PMID: 36648616 DOI: 10.1245/s10434-022-12970-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 11/14/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Frailty is a physiologic state that affects perioperative outcomes. Studies evaluating the impact of frailty on long-term oncologic outcomes are limited. This study evaluated perioperative and long-term oncologic outcomes for elderly patients undergoing colorectal surgery. METHODS Patients older than 65 years at the time of colorectal resection between July 2011 and September 2020 at Roswell Park Comprehensive Cancer Center were identified. Variables from the National Surgical Quality Improvement Program (NSQIP), the tumor registry, and electronic medical records (EMRs) were used to identify frail patients using the revised Risk Analysis Index (RAI-A) score. A score of 38 or higher defined a patient as "frail." Perioperative outcomes were evaluated using logistic regression and chi-square, and oncologic outcomes were evaluated using Kaplan-Meier analysis. RESULTS The study analyzed 411 patients. The mean age at surgery was 75.1 years. The median RAI-A score was 37, and 29.9 % of the patients were frail. The frail patients had significantly higher rates of overall complications (30.1 % vs 14.6 %; p < 0.001). They also had significantly higher rates of postoperative hospitalization longer than 30 days, postoperative delirium, and discharge to rehabilitation. No mortality differences were observed. The 318 patients with colorectal adenocarcinoma undergoing curative-intent resection were evaluated for oncologic outcomes. No differences with frailty in terms of overall survival, disease-specific survival, or progression-free survival were observed except for frail patients with stage 0 or 1 adenocarcinoma, who had worse overall survival than non-frail patients but equivalent other outcomes. CONCLUSIONS For elderly patients undergoing colorectal surgery, frailty is associated with higher postoperative complications, discharge to rehabitation, and prolonged hospitalization rates. Frailty does not affect long-term oncologic outcomes, so frail elderly patients gain the same oncologic benefit with surgery as non-frail patients.
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Affiliation(s)
- Eihab Abdelfatah
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
- Long Island School of Medicine, Division of Surgical Oncology, NYU Langone Health, Mineola, NY, USA
| | | | - Leonid Cherkassky
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Kristin Cianchetti
- Department of Quality and Patient Safety, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Gary Mann
- Department of Surgical Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA.
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Lee D, Wang A, Augustin B, Buajitti E, Tahasildar B, Carli F, Gillis C. Socioeconomic status influences participation in cancer prehabilitation and preparation for surgical recovery: A pooled retrospective analysis using a validated area-level socioeconomic status metric. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:512-520. [PMID: 36435646 DOI: 10.1016/j.ejso.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 10/31/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND Prehabilitation employs exercise, nutrition, and psychological interventions to optimize physiological status in preparation for surgery. First, we described the extent to which material deprivation index score (MDIS) influenced prehabilitation participation. Second, we evaluated the extent to which prehabilitation influenced recovery as compared to control. METHODS Pooled patient records from prospective multimodal prehabilitation studies in oncologic surgery were retrospectively examined. Patient postal codes were linked to their MDIS, a validated area-level socioeconomic status (SES) metric, as quintiles 1-5 (1 = highest SES). Functional capacity was evaluated with the 6-min walking test (6MWT) at baseline, before, and 8 weeks post-surgery. Influence of prehabilitation on length of hospital stay (LOS) was explored using generalized linear models with a negative binomial distribution adjusted for age, sex, surgical population, and MDIS. RESULTS Recruitment records were available from 2014 onwards, yielding 1013 eligible patients for prehabilitation participation with MDIS data. Fewer patients with a low SES enrolled (Q1:62% vs. Q5:47%; P = 0.01) and remained in prehabilitation studies (Q1: 59% vs. Q5: 45%; P = 0.07). Prehabilitation study records were available from 2008 onward, yielding 886 enrolled patients with MDIS data (n = 510 prehabilitation, n = 376 control). Preoperative 6MWT similarly improved by > 20 m in response to prehabilitation across SES strata (P < 0.05). Postoperative 6MWT could not be evaluated due to substantial missing data. Prehabilitation had a significant protective influence on LOS, as compared to control, in unadjusted and adjusted models [adjusted IRR:0.77 (95% CI:0.68 to 0.87; P < 0.001]. CONCLUSION Findings suggest that prehabilitation is effective across all SES; however, participation across SES quintiles was not equal. Barriers to participation must be identified and addressed. Once these barriers are addressed, prehabilitation may reduce surgical disparities among SES.
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Affiliation(s)
- Dillon Lee
- Faculty of Medicine, McGill University, Montreal, QC, Canada
| | - Ao Wang
- Medical School for International Health, Ben-Gurion University of the Negev Be'er Sheva, 8410501, Israel
| | - Berson Augustin
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Emmalin Buajitti
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | | | - Francesco Carli
- Department of Anesthesia, McGill University, Montréal, QC, Canada
| | - Chelsia Gillis
- School of Human Nutrition, McGill University, Sainte-Anne-de-Bellevue, Quebec, Canada; Department of Anesthesia, McGill University, Montréal, QC, Canada; Department of Surgery, McGill University, Montreal, QC, Canada.
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Andersson M, Egenvall M, Danielsson J, Thorell A, Sturesson C, Soop M, Nygren-Bonnier M, Rydwik E. CANOPTIPHYS study protocol: Optimising PHYSical function before CANcer surgery: effects of pre-operative optimisation on complications and physical function after gastrointestinal cancer surgery in older people at risk-a multicentre, randomised, parallel-group study. Trials 2023; 24:41. [PMID: 36658653 PMCID: PMC9850586 DOI: 10.1186/s13063-022-07026-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 12/15/2022] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND This multicentre study explores the effects of pre-operative exercise on physical fitness, post-operative complications, recovery, and health-related quality of life in older individuals with low pre-operative physical capacity scheduled to undergo surgery for colorectal cancer. We hypothesise that this group of patients benefit from pre-operative exercise in terms of improved pre-operative physical function and lower rates of post-operative complications after surgery compared to usual care. Standardised cancer pathways in Sweden dictate a timeframe of 14-28 days from suspicion of cancer to surgery for colorectal cancer. Therefore, an exercise programme aimed to enhance physical function in the limited timeframe requires a high-intensity and high-frequency approach. METHODS Participants will be included from four sites in Stockholm, Sweden. A total of 160 participants will be randomly assigned to intervention or control conditions. Simple randomisation (permuted block randomisation) is applied with a 1:1 allocation ratio. The intervention group will perform home-based exercises (inspiratory muscle training, aerobic exercises, and strength exercises) supervised by a physiotherapist (PT) for a minimum of 6 sessions in the pre-operative period, complemented with unsupervised exercise sessions in between PT visits. The control group will receive usual care with the addition of advice on health-enhancing physical activity. The physical activity behaviour in both groups will be monitored using an activity monitor. The primary outcomes are (1) change in physical performance (6-min walking distance) in the pre-operative period and (2) post-operative complications 30 days after surgery (based on Clavien-Dindo surgical score). DISCUSSION If patients achieve functional benefits by exercise in the short period before surgery, this supports the implementation of exercise training as a clinical routine. If such benefits translate into lower complication rates and better post-operative recovery or health-related quality of life is not known but would further strengthen the case for pre-operative optimisation in colorectal cancer. TRIAL REGISTRATION ClinicalTrials.gov NCT04878185. Registered on 7 May 2021. https://clinicaltrials.gov/ct2/home.
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Affiliation(s)
- Mikael Andersson
- grid.4714.60000 0004 1937 0626Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden
| | - Monika Egenvall
- grid.4714.60000 0004 1937 0626Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Department of Pelvic Cancer, Colorectal Surgery Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Danielsson
- grid.4714.60000 0004 1937 0626Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden
| | - Anders Thorell
- grid.4714.60000 0004 1937 0626Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden ,grid.414628.d0000 0004 0618 1631Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Christian Sturesson
- grid.24381.3c0000 0000 9241 5705Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Mattias Soop
- grid.4714.60000 0004 1937 0626Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden ,grid.414628.d0000 0004 0618 1631Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Malin Nygren-Bonnier
- grid.4714.60000 0004 1937 0626Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Theme Women’s Health and Allied Health Professionals, Medical Unit Occupational Therapy & Physiotherapy, Karolinska University Hospital, Stockholm, Sweden
| | - Elisabeth Rydwik
- grid.4714.60000 0004 1937 0626Department of Neurobiology, Care Sciences and Society, Division of Physiotherapy, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Theme Women’s Health and Allied Health Professionals, Medical Unit Occupational Therapy & Physiotherapy, Karolinska University Hospital, Stockholm, Sweden ,Stockholm Region Council, FOU nu, Research and Development Unit for the Elderly, Järfälla, Sweden
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Jain SR, Kandarpa VL, Yaow CYL, Tan WJ, Ho LML, Sivarajah SS, Ng JL, Chong CXZ, Aw DKL, Foo FJ, Koh FHX. The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis. World J Surg 2023; 47:86-102. [PMID: 36184673 DOI: 10.1007/s00268-022-06761-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery. METHODS Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien-Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity. RESULTS Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781-0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674-53.673, p = 0.005), but there were no significant differences in the 6MWT at 4 weeks (SMD = 30.342, 95% CI - 2.707-63.391, p = 0.066) and 8 weeks (SMD = 24.563, 95% CI - 6.77-55.900, p = 0.104) postoperatively. CONCLUSIONS As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.
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Affiliation(s)
- Sneha Rajiv Jain
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Vasundhara Lakshmi Kandarpa
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Clyve Yu Leon Yaow
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Dr, Singapore, 117597, Singapore
| | - Winson JianHong Tan
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Leonard Ming Li Ho
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Sharmini Su Sivarajah
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Jia Lin Ng
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Cheryl Xi Zi Chong
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Darius Kang Lie Aw
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Fung Joon Foo
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore
| | - Frederick Hong Xiang Koh
- Department of General Surgery, Sengkang General Hospital, SingHealth, 110 Sengkang East Way, Singapore, 544886, Singapore.
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical Practice Guidelines for Enhanced Recovery After Colon and Rectal Surgery From the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Dis Colon Rectum 2023; 66:15-40. [PMID: 36515513 PMCID: PMC9746347 DOI: 10.1097/dcr.0000000000002650] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jennifer L. Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Traci L. Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Timothy E. Miller
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, Quebec, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, Ohio
| | - Benjamin D. Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, Illinois
| | - Joel E. Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel L. Feingold
- Department of Surgery, Section of Colorectal Surgery, Rutgers University, New Brunswick, New Jersey
| | - Amy L. Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic
| | - Ian M. Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Irani JL, Hedrick TL, Miller TE, Lee L, Steinhagen E, Shogan BD, Goldberg JE, Feingold DL, Lightner AL, Paquette IM. Clinical practice guidelines for enhanced recovery after colon and rectal surgery from the American Society of Colon and Rectal Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons. Surg Endosc 2023; 37:5-30. [PMID: 36515747 PMCID: PMC9839829 DOI: 10.1007/s00464-022-09758-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 12/15/2022]
Abstract
The American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) are dedicated to ensuring high-quality innovative patient care for surgical patients by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus as well as minimally invasive surgery. The ASCRS and SAGES society members involved in the creation of these guidelines were chosen because they have demonstrated expertise in the specialty of colon and rectal surgery and enhanced recovery. This consensus document was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus and develop clinical practice guidelines based on the best available evidence. While not proscriptive, these guidelines provide information on which decisions can be made and do not dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. These guidelines should not be deemed inclusive of all proper methods of care nor exclusive of methods of care reasonably directed toward obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all the circumstances presented by the individual patient. This clinical practice guideline represents a collaborative effort between the American Society of Colon and Rectal Surgeons (ASCRS) and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and was approved by both societies.
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Affiliation(s)
- Jennifer L Irani
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Traci L Hedrick
- Department of Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Timothy E Miller
- Duke University Medical Center Library, Duke University School of Medicine, Durham, NC, USA
| | - Lawrence Lee
- Department of Surgery, McGill University, Montreal, QC, Canada
| | - Emily Steinhagen
- Department of Surgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA
| | - Benjamin D Shogan
- Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Joel E Goldberg
- Department of Surgery, Division of Colorectal Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel L Feingold
- Section of Colorectal Surgery, Rutgers University, New Brunswick, NJ, USA
| | - Amy L Lightner
- Department of Colorectal Surgery, Cleveland Clinic Foundation, Cleveland Clinic, Cleveland, USA
| | - Ian M Paquette
- Division of Colon and Rectal Surgery, University of Cincinnati College of Medicine Surgery (Colon and Rectal), 222 Piedmont #7000, Cincinnati, OH, 45219, USA.
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Guo Y, Ding L, Miao X, Jiang X, Xu T, Xu X, Zhu S, Xu Q, Hu J. Effects of prehabilitation on postoperative outcomes in frail cancer patients undergoing elective surgery: a systematic review and meta-analysis. Support Care Cancer 2023; 31:57. [PMID: 36534300 DOI: 10.1007/s00520-022-07541-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE This systematic review and meta-analys is aimed to explore the effects of prehabilitation on postoperative outcomes in frail cancer patients. METHODS A comprehensive literature search was conducted using PubMed, Cochrane Library, Embase, Web of Science, CINAHL Complete, and other databases from database inception to 15 March 2022. Studies were included if they consisted of a prehabilitation intervention in frail cancer patients undergoing elective surgery. RESULTS A total of 9 studies encompassing 1313 patients were included in the review. Through meta-analysis, prehabilitation has a positive impact on total complications (RR = 0.83, 95% CI = 0.73 to 0.94, P = 0.004), severe complications (RR = 0.62, 95% CI = 0.43 to 0.90, P = 0.01), and the average length of hospital stay (MD = - 1.36, 95% CI = - 2.38 to - 0.35, P = 0.008). But it had no differences in 30-day and 3-month mortality and 30-day and 3-month readmission rates. Through qualitative synthesis, two studies found that prehabilitation had a favorable tendency to promote functional recovery compared with the control group. CONCLUSION Prehabilitation had a positive effect on postoperative complications and the average length of hospital stay in frail cancer patients. A personalized and supervised multimodal prehabilitation program with exercise at its core may be more beneficial for them. More studies with extensive follow-up are needed to confirm and update the findings of these results.
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Heil TC, Verdaasdonk EGG, Maas HAAM, van Munster BC, Rikkert MGMO, de Wilt JHW, Melis RJF. Improved Postoperative Outcomes after Prehabilitation for Colorectal Cancer Surgery in Older Patients: An Emulated Target Trial. Ann Surg Oncol 2023; 30:244-254. [PMID: 36197561 PMCID: PMC9533971 DOI: 10.1245/s10434-022-12623-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The aim of this study was to assess the effect of a multimodal prehabilitation program on perioperative outcomes in colorectal cancer patients with a higher postoperative complication risk, using an emulated target trial (ETT) design. PATIENTS AND METHODS An ETT design including overlap weighting based on propensity score was performed. The study consisted of all patients with newly diagnosed colorectal cancer (2016-2021), in a large nonacademic training hospital, who were candidate to elective colorectal cancer surgery and had a higher risk for postoperative complications defined by: age ≥ 65 years and or American Society of Anesthesiologists score III/IV. Intention-to-treat (ITT) and per-protocol analyses were performed to evaluate the effect of prehabilitation compared with usual care on perioperative complications and length of stay (LOS). RESULTS Two hundred fifty-one patients were included: 128 in the usual care group and 123 patients in the prehabilitation group. In the ITT analysis, the number needed to treat to reduce one or more complications in one person was 4.2 (95% CI 2.6-10). Compared with patients in the usual care group, patients undergoing prehabilitation had a 55% lower comprehensive complication score (95% CI -71 to -32%). There was a 33% reduction (95% CI -44 to -18%) in LOS from 7 to 5 days. CONCLUSIONS This study showed a clinically relevant reduction of complications and LOS after multimodal prehabilitation in patients undergoing colorectal cancer surgery with a higher postoperative complication risk. The study methodology used may serve as an example for further larger multicenter comparative effectiveness research on prehabilitation.
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Affiliation(s)
- Thea C. Heil
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Huub A. A. M. Maas
- Department of Geriatric Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Barbara C. van Munster
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - René J. F. Melis
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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Lobo DN, Pavel Skořepa, Gomez D, Greenhaff PL. Prehabilitation: high-quality evidence is still required. Br J Anaesth 2023; 130:9-14. [PMID: 36328811 DOI: 10.1016/j.bja.2022.09.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/11/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Prehabilitation comprises multidisciplinary healthcare interventions, including exercise, nutritional optimisation, and psychological preparation, which aim to dampen the metabolic response to surgery, shorten the period of recovery, reduce complications, and improve the quality of recovery and quality of life. This editorial evaluates the potential benefits and limitations of and barriers to prehabilitation in surgical patients. The results of several randomised clinical trials and meta-analyses on prehabilitation show differing results, and the strength of the evidence is relatively weak. Heterogeneity in patient populations, interventions, and outcome measures, with a wide range for compliance, contribute to this variation. Evidence could be strengthened by the conduct of large-scale, appropriately powered multicentre trials that have unequivocal clinically relevant and patient-centric endpoints. Studies on prehabilitation should concentrate on recruiting patients who are frail and at high risk. Interventions should be multimodal and exercise regimens should be tailored to each patient's ability with longitudinal measurements of impact.
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Affiliation(s)
- Dileep N Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
| | - Pavel Skořepa
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; Department of Military Internal Medicine and Military Hygiene, Faculty of Military Health Sciences, University of Defence, Hradec Kralove, Czech Republic
| | - Dhanwant Gomez
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Paul L Greenhaff
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK; Musculoskeletal Disease Theme, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham, UK
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Sukys JM, Jiang R, Manes RP. Assessing Risk of Severe Complications after Endoscopic Transnasal Transsphenoidal Surgery: A Comparison of Frailty, American Society of Anesthesiologists, and Comorbidity Scores. J Neurol Surg B Skull Base 2022; 83:536-547. [PMID: 36097501 PMCID: PMC9462967 DOI: 10.1055/s-0041-1740577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022] Open
Abstract
Objective This study aimed to improve age-independent risk stratification for patients undergoing endoscopic transnasal transsphenoidal (TNTS) approach to pituitary mass resection by investigating the associations between frailty, American Society of Anesthesiologists (ASA), and comorbidity scores with severe complications following TNTS. Design This study is a retrospective review. Setting This review was conducted utilizing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. Participants A total of 680 cases of TNTS identified from 2010 to 2013 were included in this study. Main Outcome Measures The modified frailty index (mFI) was calculated to quantify frailty. ASA and Charlson's comorbidity index (CCI) scores were obtained as physiologic status and comorbidity-based prognostic markers. Severe complications were separated into intensive care unit (ICU)-level complications, defined by Clavien-Dindo grade IV (CDIV) criteria, and mortality. Results Overall, 24 CDIV complications (3.5%) and 6 deaths (0.9%) were recorded. Scores for mFI ( p = 0.01, R 2 = 0.97) and ASA ( p = 0.04., R 2 = 0.87) were significantly correlated with CDIV complications. ASA scores were significantly correlated with mortality ( p = 0.03, R 2 = 0.87), as well as independently associated with CDIV complication by multivariable regression models (odds ratio [OR] = 2.96, 95% confidence interval [CI]: 1.35-6.83, p < 0.01), while mFI was not. CCI was not significantly associated with CDIV complications or mortality. A multivariable regression model incorporating ASA had a lower Akaike's Information Criteria (AIC; 188.55) than a model incorporating mFI (195.99). Conclusion Frailty and physiologic status, as measured by mFI and ASA scores respectively, both correlate with ICU-level complications after TNTS. ASA scores demonstrate greater clinical utility than mFI scores; however, as they are more easily generated, uniquely correlated with mortality and independently associated with ICU-level complication risk on multivariable regression analysis.
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Affiliation(s)
- Jordan M. Sukys
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
- Address for correspondence Jordan M. Sukys, MD 47 College Place, Suite 216, New Haven, Connecticut 06510United States
| | - Roy Jiang
- Department of Surgery, Division of Otolaryngology, Yale University School of Medicine, New Haven, Connecticut, United States
| | - Richard P. Manes
- Division of Otolaryngology, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut, United States
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Esser T, Zimmer P, Schier R. Preoperative exercise and prehabilitation. Curr Opin Anaesthesiol 2022; 35:667-673. [PMID: 36156505 DOI: 10.1097/aco.0000000000001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this narrative review is to give an overview about the effects of multimodal prehabilitation and current existing and prospectively planned studies. The potential efficacy of exercise in the context of prehabilitation ranges from preoperatively improving patients' functional capacity to inducing cellular mechanisms that affect organ perfusion via endothelial regeneration, anti-inflammatory processes and tumour defense. RECENT FINDINGS Current studies show that prehabilitation is capable of reducing certain postoperative complications and length of hospital stay in certain patient populations. These findings are based on small to mid-size trials with large heterogeneity, lacking generalizability and evidence that prehabilitation has positive effects on long term survival. SUMMARY The concept of prehabilitation contains the features, namely preoperative exercise, nutritional intervention and psychological support. Preoperative exercise holds potential molecular effects that can be utilized in the perioperative period in order to improve patients' postoperative outcome. Future multimodal prehabilitation trials must specifically clarify the clinical impact of this concept on patients' quality of life after major cancer surgery and cancer-specific survival.
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Affiliation(s)
- Tobias Esser
- Institute of Sports and Sports Medicine, TU Dortmund University, Dortmund
| | - Philipp Zimmer
- Institute of Sports and Sports Medicine, TU Dortmund University, Dortmund
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anaesthesiology and Intensive Care Medicine, Cologne, Germany
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Bauer CJ, Findlay M, Koliamitra C, Zimmer P, Schick V, Ludwig S, Gurtner GC, Riedel B, Schier R. Preoperative exercise induces endothelial progenitor cell mobilisation in patients undergoing major surgery – A prospective randomised controlled clinical proof-of-concept trial. Heliyon 2022; 8:e10705. [PMID: 36200018 PMCID: PMC9529507 DOI: 10.1016/j.heliyon.2022.e10705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 05/10/2022] [Accepted: 09/14/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Prehabilitation is increasingly recognised as a therapeutic option to reduce postoperative complications. Investigating the beneficial effects of exercise on cellular mechanisms, we have previously shown that a single episode of exhaustive exercise effectively stimulates endothelial progenitor cells (a cell population associated with vascular maintenance, repair, angiogenesis, and neovascularization) in correlation with fewer postoperative complications, despite the ongoing debate about the appropriate cell surface marker profiles of these cells (common phenotypical definitions include CD45dim, CD133+, CD34+ and/or CD31+). In order to translate these findings into clinical application, a feasible prehabilitation programme achieving both functional and cellular benefits in a suitable timeframe to expedite surgery is necessary. Objective The objective of this study was to test the hypothesis that a four-week prehabilitation programme of vigorous-intensity interval exercise training is feasible, increases physical capacity (primary outcome) and the circulatory number of endothelial progenitor cells within peripheral blood. Methods In this unblinded, parallel-group, randomised controlled proof-of-concept clinical trial (German Clinical Trial Register number: DRKS00000527) conducted between 01st December 2014 and 30th November 2016, fifteen female adult patients scheduled for incontinence surgery with abdominal laparotomy at the University Hospital Cologne were allocated to either an exercise (n = 8, exclusion of 1 patient, analysed n = 7) or non-exercise group (n = 7, exclusion of 1 patient, analysed n = 6). The exercise group's intervention consisted of a vigorous-intensity interval training for four weeks preoperatively. Cardiopulmonary Exercise Testing accompanied by peripheral blood collection was performed before and after the (non-)training phase. Cellular investigations were conducted by flow cytometry and cluster-based analyses. Results Vigorous-intensity interval training over four weeks was feasible in the exercise group (successful completion by 8 out of 8 patients without any harms), with significant improvements in patients' functional capacity (increased oxygen uptake at anaerobic threshold [intervention group mean + 1.71 ± 3.20 mL/min/kg vs. control group mean −1.83 ± 2.14 mL/min/kg; p = 0.042] and peak exercise [intervention group mean + 1.71 ± 1.60 mL/min/kg vs. control group mean −1.67 ± 1.37 mL/min/kg; p = 0.002]) and a significant increase in the circulatory number of endothelial progenitor cells (proportionate CD45dim/CD14dim/CD133+/CD309+/CD34+/CD31 + subpopulation within the circulating CD45-pool [p = 0.016]). Conclusions We introduce a novel prehabilitation concept that shows effective stimulation of an endothelial progenitor cell subpopulation within four weeks of preoperative exercise, serving as a clinical cell-mediated intervention with the aim to reduce surgical complications. Funding Institutional funding. DFG (German Research Foundation, 491454339) support for the Article Processing Charge.
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Affiliation(s)
- Claus Juergen Bauer
- Department of Internal Medicine—Oncology, Hematology and Rheumatology, University Hospital Bonn, Bonn, Germany
| | - Michael Findlay
- Department of Surgery, Division of Cancer Surgery, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Christina Koliamitra
- Institute for Cardiovascular Research and Sports Medicine, German Sports University Cologne, Cologne, Germany
| | - Philipp Zimmer
- Institute of Sports and Sports Medicine, TU Dortmund University, Dortmund, Germany
| | - Volker Schick
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sebastian Ludwig
- Department of Obstetrics and Gynaecology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Geoffrey C. Gurtner
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, USA
| | - Bernhard Riedel
- Department of Anaesthetics, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Robert Schier
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Corresponding author.
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Sleight A, Gerber LH, Marshall TF, Livinski A, Alfano CM, Harrington S, Flores AM, Virani A, Hu X, Mitchell SA, Varedi M, Eden M, Hayek S, Reigle B, Kerkman A, Neves R, Jablonoski K, Hacker ED, Sun V, Newman R, McDonnell KK, L'Hotta A, Schoenhals A, Dpt NLS. Systematic Review of Functional Outcomes in Cancer Rehabilitation. Arch Phys Med Rehabil 2022; 103:1807-1826. [PMID: 35104445 PMCID: PMC9339032 DOI: 10.1016/j.apmr.2022.01.142] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 11/02/2022]
Abstract
OBJECTIVE To systematically review the evidence regarding rehabilitation interventions targeting optimal physical or cognitive function in adults with a history of cancer and describe the breadth of evidence as well as strengths and limitations across a range of functional domains. DATA SOURCES PubMed, Cumulative Index to Nursing and Allied Health Plus, Scopus, Web of Science, and Embase. The time scope was January 2008 to April 2019. STUDY SELECTION Prospective, controlled trials including single- and multiarm cohorts investigating rehabilitative interventions for cancer survivors at any point in the continuum of care were included, if studies included a primary functional outcome measure. Secondary data analyses and pilot/feasibility studies were excluded. Full-text review identified 362 studies for inclusion. DATA EXTRACTION Extraction was performed by coauthor teams and quality and bias assessed using the American Academy of Neurology (AAN) Classification of Evidence Scheme (class I-IV). DATA SYNTHESIS Studies for which the functional primary endpoint achieved significance were categorized into 9 functional areas foundational to cancer rehabilitation: (1) quality of life (109 studies), (2) activities of daily living (61 studies), (3) fatigue (59 studies), (4) functional mobility (55 studies), (5) exercise behavior (37 studies), (6) cognition (20 studies), (7) communication (10 studies), (8) sexual function (6 studies), and (9) return to work (5 studies). Most studies were categorized as class III in quality/bias. Averaging results found within each of the functional domains, 71% of studies reported statistically significant results after cancer rehabilitation intervention(s) for at least 1 functional outcome. CONCLUSIONS These findings provide evidence supporting the efficacy of rehabilitative interventions for individuals with a cancer history. The findings should be balanced with the understanding that many studies had moderate risk of bias and/or limitations in study quality by AAN criteria. These results may provide a foundation for future work to establish clinical practice guidelines for rehabilitative interventions across cancer disease types.
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Affiliation(s)
- Alix Sleight
- Department of Physical Medicine and Rehabilitation, Cedars-Sinai Medical Center, Los Angeles, California, United States; Center for Integrated Research in Cancer and Lifestyle (CIRCL), Cedars-Sinai Medical Center, Los Angeles, California, United States; Cedars Sinai Cancer, Los Angeles, California, United States; Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, United States.
| | - Lynn H Gerber
- College of Health and Human Services, George Mason University, Fairfax County, Virginia, United States; Inova Health System, Inova Medicine Services, Falls Church, Virginia, United States
| | | | - Alicia Livinski
- National Institutes of Health Library, Office of Research Services, National Institutes of Health, Bethesda, Maryland, United States
| | - Catherine M Alfano
- Northwell Health Cancer Institute, New Hyde Park, New York, United States; Center for Personalized Health, Feinstein Institutes for Medical Research, Manhasset, New York, United States; Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, United States
| | - Shana Harrington
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, United States
| | - Ann Marie Flores
- Department of Physical Therapy and Human Movement Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States; Robert H. Lurie Comprehensive Cancer Center, Cancer Survivorship Institute, Chicago, Illinois, United States
| | - Aneesha Virani
- Rehabilitation Department, Northside Hospital, Atlanta, Georgia, United States
| | - Xiaorong Hu
- Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Boston, Massachusetts, United States; Rehabilitation Medicine School, Nanjing Medical University, Nanjing, China
| | - Sandra A Mitchell
- Outcomes Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland, United States
| | - Mitra Varedi
- Epidemiology and Cancer Control Department, St Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Melissa Eden
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Scottsdale, Arizona, United States
| | - Samah Hayek
- Clalit Health Services, Clalit Research Institute, Ramat-Gan, Israel
| | - Beverly Reigle
- College of Nursing, University of Cincinnati, Cincinnati, Ohio, United States
| | - Anya Kerkman
- Lincoln Cancer Rehabilitation, Lincoln, Nebraska, United States; CHI Health St Elizabeth, Lincoln, Nebraska, United States
| | - Raquel Neves
- Czech Rehabilitation Hospital, Al Ain, United Arab Emirates
| | - Kathleen Jablonoski
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, United States; Department of Biostatistics, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | - Eileen Danaher Hacker
- Department of Science of Nursing Care, Indiana University School of Nursing, Indianapolis, Indiana, United States
| | - Virginia Sun
- Department of Population Sciences, City of Hope, Duarte, California, United States; Department of Surgery, City of Hope, Duarte, California, United States
| | - Robin Newman
- Department of Occupational Therapy, Boston University College of Health and Rehabilitation Sciences: Sargent College, Boston, Massachusetts, United States
| | - Karen Kane McDonnell
- College of Nursing, University of South Carolina, Columbia, South Carolina, United States
| | - Allison L'Hotta
- Department of Occupational Therapy, Washington University in St Louis, St Louis, Missouri, United States
| | - Alana Schoenhals
- Mrs T.H. Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, California, United States
| | - Nicole L Stout Dpt
- West Virginia University Cancer Institute, West Virginia University School of Public Health, Morgantown, West Virginia, United States; Rehabilitation Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, United States
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Chmelo J, Phillips AW, Greystoke A, Charman SJ, Avery L, Hallsworth K, Welford J, Cooper M, Sinclair RCF. A feasibility trial of prehabilitation before oesophagogastric cancer surgery using a multi-component home-based exercise programme: the ChemoFit study. Pilot Feasibility Stud 2022; 8:173. [PMID: 35945625 PMCID: PMC9360697 DOI: 10.1186/s40814-022-01137-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 07/28/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment for locally advanced oesophagogastric adenocarcinoma involves neoadjuvant chemotherapy which has a negative impact on patient fitness. Using 'prehabilitation' to increase activity levels and fitness may affect physiology, postoperative outcomes and improve patient wellbeing and quality of life. The aims of the trial were to address the feasibility and acceptability of recruiting participants to a home-based prehabilitation programme and provide data to allow design of future studies. METHODS We recruited patients to a single-arm feasibility trial of home-based exercise prehabilitation. Eligible patients were aged ≥18years, had operable oesophageal or gastric adenocarcinoma and were receiving neoadjuvant chemotherapy at our tertiary referral hospital. All participants commenced a home-based exercise programme utilising pedometers and step counting to target daily aerobic exercise sessions alongside daily strengthening exercises. A weekly telephone consultation directed the exercise programme and facilitated weekly data collection. The primary (feasibility) outcomes for the trial were (a) recruitment rate, (b) completion rate, (c) engagement with the programme (use of pedometers, recording step counts, telephone consultations) and (d) compliance with exercise sessions, exercise intensity and strengthening exercises. RESULTS There were 42 patients recruited, and the recruitment rate was 72.4% (42/58). 92.3% (36/39) of patients completed the exercise programme. There was 98.7% (IQR 93.2-100.0%) compliance with wearing a pedometer and recording data, and 100.0% (IQR 93.1-100.0%) compliance with a weekly telephone consultation. Exercise sessions and strengthening exercises were completed 70.2% (IQR 53.1-88.9%) and 69.4% (IQR 52.1-84.3%) of the time, respectively. Appropriate exercise intensity was recorded 96% (IQR 85.4-99.4%) of the time. There were no adverse events. Participants were enrolled in the exercise programme for a median of 91 days (IQR 84 to 105 days). CONCLUSIONS The results of this trial support the feasibility and acceptability of recruiting participants to an appropriately powered randomised controlled trial of prehabilitation. TRIAL REGISTRATION Clinicaltrials.gov NCT04194463 . Registered on 11th December 2019-retrospectively registered.
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Affiliation(s)
- Jakub Chmelo
- Northern Oesophago-gastric unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE4 1LP, UK. .,Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
| | - Alexander W Phillips
- Northern Oesophago-gastric unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE4 1LP, UK.,School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - Alastair Greystoke
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Sarah J Charman
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Leah Avery
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.,Centre for Rehabilitation, School of Health & Life Sciences, Teesside University, Tees Valley, UK
| | - Kate Hallsworth
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Jenny Welford
- Northern Centre for Cancer Care, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Matthew Cooper
- Centre for Rehabilitation, School of Health & Life Sciences, Teesside University, Tees Valley, UK
| | - Rhona C F Sinclair
- Department of Anaesthesia and Critical Care, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Zhang X, Wang S, Ji W, Wang H, Zhou K, Jin Z, Bo L. The effect of prehabilitation on the postoperative outcomes of patients undergoing colorectal surgery: A systematic review and meta-analysis. Front Oncol 2022; 12:958261. [PMID: 35965591 PMCID: PMC9372464 DOI: 10.3389/fonc.2022.958261] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 07/05/2022] [Indexed: 11/30/2022] Open
Abstract
Study objective Prehabilitation is analogous to marathon training and includes preoperative preparation for exercise, as well as nutrition and psychology. However, evidence-based recommendations to guide prehabilitation before colorectal surgery are limited. We aimed to evaluate the effect of prehabilitation on the postoperative outcomes of patients undergoing colorectal surgery. Design This study is a systematic review and meta-analysis. Methods The PubMed, Embase, and Cochrane databases were searched for studies reporting the effect of prehabilitation strategies versus standard care or rehabilitation in patients undergoing colorectal surgery. The primary outcomes were overall postoperative complications and length of hospital stay (LOS), and the secondary outcome was functional capacity (measured using the 6-min walk test [6MWT]) at 4 and 8 weeks after surgery. Main results Fifteen studies with 1,306 participants were included in this meta-analysis. The results showed no significant reduction in the number of overall postoperative complications (risk ratio = 1.02; 95% confidence interval [CI] = 0.79–1.31; p = 0.878) or LOS (standardized mean difference = 0.04; 95% CI = −0.11 to 0.20; p = 0.589) in patients who underwent colorectal surgery with or without prehabilitation strategy. Additionally, there were no significant differences in the functional capacity estimated using the 6MWT at 4 and 8 weeks postoperatively. Conclusions Prehabilitation did not significantly affect the number of postoperative complications, LOS, or functional capacity of patients undergoing colorectal surgery. Whether prehabilitation should be recommended deserves further consideration. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=290108, identifier CRD42021290108
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Affiliation(s)
- Xiaoting Zhang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shaokang Wang
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Wentao Ji
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Huixian Wang
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Keqian Zhou
- College of Basic Medicine, Naval Medical University, Shanghai, China
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, Shanghai, China
- *Correspondence: Lulong Bo, ; Zhichao Jin,
| | - Lulong Bo
- Faculty of Anesthesiology, Changhai Hospital, Naval Medical University, Shanghai, China
- *Correspondence: Lulong Bo, ; Zhichao Jin,
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38
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Dhanis J, Keidan N, Blake D, Rundle S, Strijker D, van Ham M, Pijnenborg JMA, Smits A. Prehabilitation to Improve Outcomes of Patients with Gynaecological Cancer: A New Window of Opportunity? Cancers (Basel) 2022; 14:cancers14143448. [PMID: 35884512 PMCID: PMC9351657 DOI: 10.3390/cancers14143448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/30/2022] [Accepted: 07/11/2022] [Indexed: 12/02/2022] Open
Abstract
Simple Summary Surgery is an important mainstay in the treatment of gynaecological cancers but is associated with operative complications, especially for those with poor physical and mental health. Prehabilitation is a new and upcoming strategy to optimise patients’ functional capacity, nutritional status and psychosocial wellbeing in order to reduce complications and enhance recovery. In this review, we assessed the evidence on prehabilitation programmes for patients with gynaecological cancer. The limited evidence shows that prehabilitation may reduce length of hospital stay for ovarian cancer patients, and may result in significant weight loss in patients with endometrial and cervical cancer. Comparative prospective studies are required to determine the effectiveness of prehabilitation on reducing operative complications and improving quality of life, and to further specify the content of such a programme for patients with gynaecological cancer. Abstract The literature evaluating the effect of prehabilitation programmes on postoperative outcomes and quality of life of patients with gynaecological cancer undergoing surgery was reviewed. Databases including Pubmed, Medline, EMBASE (Ovid) and PsycINFO were systematically searched to identify studies evaluating the effect of prehabilitation programmes on patients with gynaecological cancer. Both unimodal and multimodal prehabilitation programmes were included encompassing physical exercise and nutritional and psychological support. Primary outcomes were surgical complications and quality of life. Secondary outcomes were anthropometric changes and adherence to the prehabilitation programme. Seven studies fulfilled the inclusion criteria, comprising 580 patients. Included studies were nonrandomised prospective studies (n = 4), retrospective studies (n = 2) and one case report. Unimodal programmes and multimodal programmes were included. In patients with ovarian cancer, multimodal prehabilitation resulted in significantly reduced hospital stay and time to chemotherapy. In patients with endometrial and cervical cancer, prehabilitation was associated with significant weight loss, but had no significant effects on surgical complications or mortality. No adverse events of the programmes were reported. Evidence on the effect of prehabilitation for patients with gynaecological cancer is limited. Future studies are needed to determine the effects on postoperative complications and quality of life.
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Affiliation(s)
- Joëlle Dhanis
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands; (M.v.H.); (J.M.A.P.); (A.S.)
- Faculty of Medical Sciences, Radboud University, 6526 GA Nijmegen, The Netherlands
- Correspondence: ; Tel.: +31-644404756
| | - Nathaniel Keidan
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; (N.K.); (D.B.); (S.R.)
| | - Dominic Blake
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; (N.K.); (D.B.); (S.R.)
| | - Stuart Rundle
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; (N.K.); (D.B.); (S.R.)
| | - Dieuwke Strijker
- Department of Surgery, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands;
| | - Maaike van Ham
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands; (M.v.H.); (J.M.A.P.); (A.S.)
| | - Johanna M. A. Pijnenborg
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands; (M.v.H.); (J.M.A.P.); (A.S.)
| | - Anke Smits
- Department of Obstetrics and Gynaecology, Radboud University Medical Centre, 6525 GA Nijmegen, The Netherlands; (M.v.H.); (J.M.A.P.); (A.S.)
- Department of Gynaecological Oncology, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK; (N.K.); (D.B.); (S.R.)
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Zheng Y, Mao M, Li F, Wang L, Zhang X, Zhang X, Wang H, Zhou H, Ji M, Wang Y, Liu L, Zhu Q, Reinhardt JD, Lu X. Effects of enhanced recovery after surgery plus pulmonary rehabilitation on complications after video-assisted lung cancer surgery: a multicentre randomised controlled trial. Thorax 2022; 78:574-586. [PMID: 35835552 DOI: 10.1136/thoraxjnl-2021-218183] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 05/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Lung cancer surgery is associated with a high incidence of postoperative pulmonary complications (PPCs). We evaluated whether enhanced recovery after surgery plus pulmonary rehabilitation was superior over enhanced recovery after surgery alone in reducing the incidence of postoperative PPCs and length of hospital stay. METHODS In this pragmatic multicentre, randomised controlled, parallel-group clinical trial, eligible patients scheduled for video-assisted lung cancer surgery were randomly assigned (1:1) to either a newly developed programme that integrated preoperative and postoperative pulmonary rehabilitation components into a generic thoracic enhanced recovery after surgery pathway, or routine thoracic enhanced recovery after surgery. Primary outcome was the overall occurrence of PPCs within 2 weeks after surgery. Secondary outcomes were the occurrence of specific complications, time to removal of chest drain, and length of hospital stay (LOS). RESULTS Of 428 patients scheduled for lung cancer surgery, 374 were randomised with 187 allocated to the experimental programme and 187 to control. Incidence of PPCs at 14 Days was 18.7% (35/187) in the experimental group and 33.2% (62/187) in the control group (intention-to-treat, unadjusted HR 0.524, 95% CI 0.347 to 0.792, p=0.002). Particularly, significant risk reduction was observed regarding pleural effusion, pneumonia and atelectasis. Time to removal of chest drain and LOS were not significantly reduced in the experimental group. CONCLUSIONS Adding pulmonary rehabilitation to enhanced recovery after surgery appears to be effective in reducing the incidence of PPCs, but not LOS. Standard integration of pulmonary rehabilitation into thoracic enhanced recovery after surgery is a promising approach to PPC prophylaxis. TRIAL REGISTRATION NUMBER ChiCTR1900024646.
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Affiliation(s)
- Yu Zheng
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Mao Mao
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Fang Li
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Lu Wang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Rehabilitation Medicine, Qingdao Municipal Hospital Group, Qingdao, Shandong, China
| | - Xintong Zhang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiu Zhang
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Haiming Wang
- Department of Rehabilitation Medicine, Zhengzhou University First Affiliated Hospital, Zhengzhou, Henan, China
| | - Huiqing Zhou
- Department of Rehabilitation Therapy, Taizhou Enze Medical Center, Tai Zhou, Zhejiang, China
| | - Meifang Ji
- Department of Rehabilitation Therapy, the Second Affiliated Hospital of Hainan Medical University, Hainan, China
| | - Yulong Wang
- Department of Rehabilitation Medicine, Shenzhen Dapeng New District Nan'ao People's Hospital, Shenzhen, China
| | - Liang Liu
- Department of Rehabilitation Medicine, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Quan Zhu
- Department of Thoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Jan D Reinhardt
- Institute for Disaster Management and Reconstruction, Sichuan University, Chengdu, Sichuan, China .,Swiss Paraplegic Research, Nottwil, Switzerland.,Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland.,Rehabilitation Research Center, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Xiao Lu
- Department of Rehabilitation Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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Falz R, Bischoff C, Thieme R, Lässing J, Mehdorn M, Stelzner S, Busse M, Gockel I. Effects and duration of exercise-based prehabilitation in surgical therapy of colon and rectal cancer: a systematic review and meta-analysis. J Cancer Res Clin Oncol 2022; 148:2187-2213. [PMID: 35695931 PMCID: PMC9349170 DOI: 10.1007/s00432-022-04088-w] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/23/2022] [Indexed: 12/13/2022]
Abstract
Purpose Functional capacity is an independent indicator of morbidity in colon and rectal cancer surgery. This systematic review describes the evaluated and synthesized effects of exercise prehabilitation depending on the duration of interventions on functional and postoperative outcomes in colon and rectal cancer surgery. Methods Three electronic databases (MEDLINE Pubmed, Web of Sciences, and Cochrane Registry) were systematically searched (January 2022) for controlled trials that investigated the effects of prehabilitation prior to colo-rectal cancer resection. Results Twenty-three studies were included in this systematic review and 14 in our meta-analyses assessing these outcomes: the 6 min walk distance (6MWD), postoperative overall complications, and length of stay (LOS). We observed a significant improvement in preoperative functional capacity as measured with 6MWD (mean difference: 30.8 m; 95% CI 13.3, 48.3; p = 0.0005) due to prehabilitation. No reductions in LOS (mean difference: – 0.27 days; 95% CI – 0.93, 0.40; p = 0.5) or postoperative overall complications (Odds ratio: 0.84; 95% CI 0.53, 1.31; p = 0.44) were observed. Prehabilitation lasting more than 3 weeks tended to lower overall complications (Odds ratio: 0.66; 95% CI 0.4, 1.1; p = 0.11). However, the prehabilitation time periods differed between colon and rectal carcinoma resections. Conclusion Prehabilitation while the patient is preparing to undergo surgery for colorectal carcinoma improves functional capacity; and might reduce postoperative overall complications, but does not shorten the LOS. The studies we reviewed differ in target variables, design, and the intervention’s time period. Multicenter studies with sufficient statistical power and differentiating between colon and rectal carcinoma are needed to develop implementation strategies in the health care system. Registration PROSPERO CRD42022310532
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Affiliation(s)
- Roberto Falz
- Institute of Sport Medicine and Prevention, University Leipzig, Rosa-Luxemburg-Str. 20-30, 04103, Leipzig, Germany.
| | - Christian Bischoff
- Institute of Sport Medicine and Prevention, University Leipzig, Rosa-Luxemburg-Str. 20-30, 04103, Leipzig, Germany
| | - René Thieme
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Johannes Lässing
- Institute of Sport Medicine and Prevention, University Leipzig, Rosa-Luxemburg-Str. 20-30, 04103, Leipzig, Germany
| | - Matthias Mehdorn
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Sigmar Stelzner
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Martin Busse
- Institute of Sport Medicine and Prevention, University Leipzig, Rosa-Luxemburg-Str. 20-30, 04103, Leipzig, Germany
| | - Ines Gockel
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig, Germany
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Matthews L, Levett DZH, Grocott MPW. Perioperative Risk Stratification and Modification. Anesthesiol Clin 2022; 40:e1-e23. [PMID: 35595387 DOI: 10.1016/j.anclin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This article discusses the important topic of perioperative risk stratification and the interventions that can be used in the perioperative period for risk modification. It begins with a brief overview of the commonly used scoring systems, risk-prediction models, and assessments of functional capacity and discusses some of the evidence behind each. It then moves on to examine how perioperative risk can be modified through the use of shared decision making, management of multimorbidity, and prehabilitation programs, before considering what the future of risk stratification and modification may hold.
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Affiliation(s)
- Lewis Matthews
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Shackleton Department of Anaesthesia, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton SO16 6YD, United Kingdom.
| | - Denny Z H Levett
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton/University of Southampton, Tremona Road, Southampton SO16 6YD, United Kingdom; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
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42
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Molenaar CJ, van Rooijen SJ, Fokkenrood HJ, Roumen RM, Janssen L, Slooter GD. Prehabilitation versus no prehabilitation to improve functional capacity, reduce postoperative complications and improve quality of life in colorectal cancer surgery. Cochrane Database Syst Rev 2022; 5:CD013259. [PMID: 35588252 PMCID: PMC9118366 DOI: 10.1002/14651858.cd013259.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Surgery is the cornerstone in curative treatment of colorectal cancer. Unfortunately, surgery itself can adversely affect patient health. 'Enhanced Recovery After Surgery' programmes, which include multimodal interventions, have improved patient outcomes substantially. However, these are mainly applied peri- and postoperatively. Multimodal prehabilitation includes multiple preoperative interventions to prepare patients for surgery with the aim of increasing resilience, thereby improving postoperative outcomes. OBJECTIVES To determine the effects of multimodal prehabilitation programmes on functional capacity, postoperative complications, and quality of life in adult patients undergoing surgery for colorectal cancer. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and PsycINFO in January 2021. We also searched trial registries up to March 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) in adult patients with non-metastatic colorectal cancer, scheduled for surgery, comparing multimodal prehabilitation programmes (defined as comprising at least two preoperative interventions) with no prehabilitation. We focused on the following outcomes: functional capacity (i.e. 6-minute walk test, VO2peak, handgrip strength), postoperative outcomes (i.e. complications, mortality, length of hospital stay, emergency department visits, re-admissions), health-related quality of life, compliance, safety of prehabilitation, and return to normal activities. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data, assessed risk of bias and used GRADE to assess the certainty of the evidence. Any disagreements were solved with discussion and consensus. We pooled data to perform meta-analyses, where possible. MAIN RESULTS We included three RCTs that enrolled 250 participants with non-metastatic colorectal cancer, scheduled for elective (mainly laparoscopic) surgery. Included trials were conducted in tertiary care centres and recruited patients during periods ranging from 17 months to 45 months. A total of 130 participants enrolled in a preoperative four-week trimodal prehabilitation programme consisting of exercise, nutritional intervention, and anxiety reduction techniques. Outcomes of these participants were compared to those of 120 participants who started an identical but postoperative programme. Postoperatively, prehabilitation may improve functional capacity, determined with the 6-minute walk test at four and eight weeks (mean difference (MD) 26.02, 95% confidence interval (CI) -13.81 to 65.85; 2 studies; n = 131; and MD 26.58, 95% CI -8.88 to 62.04; 2 studies; n = 140); however, the certainty of evidence is low and very low, respectively, due to serious risk of bias, imprecision, and inconsistency. After prehabilitation, the functional capacity before surgery improved, with a clinically relevant mean difference of 24.91 metres (95% CI 11.24 to 38.57; 3 studies; n = 225). The certainty of evidence was moderate due to downgrading for serious risk of bias. Prehabilitation may also result in fewer complications (RR 0.95, 95% CI 0.70 to 1.29; 3 studies; n = 250) and fewer emergency department visits (RR 0.72, 95% CI 0.39 to 1.32; 3 studies; n = 250). The certainty of evidence was low due to downgrading for serious risk of bias and imprecision. On the other hand, prehabilitation may also result in a higher re-admission rate (RR 1.20, 95% CI 0.54 to 2.65; 3 studies; n = 250). The certainty of evidence was again low due to downgrading for risk of bias and imprecision. The effect on VO2peak, handgrip strength, length of hospital stay, mortality rate, health-related quality of life, return to normal activities, safety of the programme, and compliance rate could not be analysed quantitatively due to missing or insufficient data. The included studies did not report a difference between groups for health-related quality of life and length of hospital stay. Data on remaining outcomes were not reported or were reported inadequately in the included studies. AUTHORS' CONCLUSIONS Prehabilitation may result in an improved functional capacity, determined with the 6-minute walk test both preoperatively and postoperatively. Complication rates and the number of emergency department visits postoperatively may also diminish due to a prehabilitation programme, while the number of re-admissions may be higher in the prehabilitation group. The certainty of evidence ranges from moderate to very low, due to downgrading for serious risk of bias, imprecision and inconsistency. In addition, only three heterogeneous studies were included in this review. Therefore, the findings of this review should be interpreted with caution. Numerous relevant RCTs are ongoing and will be included in a future update of this review.
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Affiliation(s)
| | | | | | - Rudi Mh Roumen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| | - Loes Janssen
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| | - Gerrit D Slooter
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
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Combining prehabilitation with enhanced recovery programs in gynecological surgery. J Gynecol Obstet Hum Reprod 2022; 51:102376. [DOI: 10.1016/j.jogoh.2022.102376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/05/2022] [Indexed: 11/24/2022]
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Multimodal prehabilitation in older adults before major abdominal surgery: a systematic review and meta-analysis. Langenbecks Arch Surg 2022; 407:2193-2204. [PMID: 35233645 DOI: 10.1007/s00423-022-02479-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE Multimodal prehabilitation aims to prepare frail older patients for major surgery. The objective of this review is to determine the benefits of pre-operative multimodal prehabilitation compared to standard care in older patients. METHODS Data sources included MEDLINE, EMBASE, CENTRAL, CINAHL and PsychINFO. They were searched from inception to September 2021. Only randomized controlled trials (RCT) with an average study population age ≥ 65 that had undergone major abdominal operation with at least two components (physical, nutritional, psychological) of prehabilitation programs were included. RESULTS Nine RCTs were included with a total of 823 patients, of whom 705 completed the study with 358 undergoing prehabilitation and 347 were controls. Significantly lower complications were observed in the prehabilitation group compared to control (OR 0.67; 95% CI 0.46 to 0.99; p = 0.04; I2 = 32%). A significant increase in 6-min walking distance (6MWD) from baseline to immediately prior to surgery (mean difference 35.1 m; 95%CI 11.6-58.4; p = 0.003; I2 = 67%) and 8 weeks post-surgery (mean difference 44.9 m; 95%CI 6.0-83.8; p = 0.02; I2 = 75%) was noted in the prehabilitation group. No difference was observed in length of stay (OR 0.59; 95% CI - 0.23 to 1.40; p = 0.16; I2 = 91%) or 30-day emergency department visit (OR 0.72; 95% CI 0.41 to 1.26; p = 0.25; I2 = 0%). Patient reported outcome measures were not significantly different. CONCLUSIONS Amongst older patients, multimodal prehabilitation increases peri-operative functional capacity and may potentially decrease post-operative complications. Future studies should continue to focus on older patients who are frail as this is the group that prehabilitation would likely have a clinically significant impact on.
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Liu C, Lu Z, Zhu M, Lu X. Trimodal prehabilitation for older surgical patients: a systematic review and meta-analysis. Aging Clin Exp Res 2022; 34:485-494. [PMID: 34227052 DOI: 10.1007/s40520-021-01929-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 06/28/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the postoperative effectiveness of trimodal prehabilitation in older surgical patients. METHODS We searched Medline, PubMed, Embase, the Cochrane Library, Web of Science, and ClinicalTrials.gov for observational cohort studies and randomised controlled trials (RCTs) of older surgical patients who underwent trimodal prehabilitation. We performed a meta-analysis to estimate the pooled risk ratio (RR) for dichotomous data and weighted mean difference (MD) for continuous data. Primary outcomes were postoperative mortality and complications, and the secondary outcomes were the 6-min walk test (6MWT) at 4 and 8 weeks after surgery, readmission, and length of hospital stay (LOS). This systematic review and meta-analysis was registered with PROSPERO (registration number: CRD42020201347). RESULTS We included 10 studies (four RCTs and six cohort studies) comprising 1553 older surgical patients (trimodal prehabilitation group, n = 581; control group, n = 972). There were no significant differences in postoperative mortality (RR 1.32; 95% confidence interval [CI] 0.52-3.35) and postoperative complications (RR 0.91; 95% CI 0.76-1.09). Prehabilitation did not reduce readmission (RR 0.92; 95% CI 0.61-1.38) and LOS (MD 0.10; 95% CI - 0.34-0.53). In a sub-analysis, trimodal prehabilitation did not significantly improve postoperative mortality, postoperative complications, readmission rates, or LOS when compared with standard care. However, trimodal prehabilitation significantly improved the 6MWT at 4 weeks after surgery (MD 37.49; 95% CI 5.81-69.18). CONCLUSIONS Our systematic review and meta-analysis demonstrated that trimodal prehabilitation did not reduce postoperative mortality and complications significantly but improved postoperative functional status in older surgical patients. Therefore, more high-quality trials are required.
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Affiliation(s)
- Chengyu Liu
- Department of General Surgery, Department of Hepato-Bilio-Pancreatic Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Zhenhua Lu
- Department of General Surgery, Department of Hepato-Bilio-Pancreatic Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Mingwei Zhu
- Department of General Surgery, Department of Hepato-Bilio-Pancreatic Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
| | - Xinlian Lu
- School of Psychology and Cognitive Science, Peking University, Beijing, 100871, People's Republic of China
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Jeske P, Wojtera B, Banasiewicz T. Prehabilitation – current role in surgery. POLISH JOURNAL OF SURGERY 2022. [DOI: 10.5604/01.3001.0015.7340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction
Prehabilitation concerns preoperative activities aimed in proper preparation to undergo a surgery and improve postoperative recovery. It includes the interdisciplinary approach by presurgical improvement of physical fitness and nourishment status, mental training and quitting addictions. The aim of the study was to investigate the recent publications in the field of prehabilitation.
Methods
We performed a systematic review in the PubMed database using the formula ‘preopreative OR before surgery, postoperative OR after surgery, prehabilitation’. The inclusion criteria were studies with a minimum population of 50 patients, including preoperative interventions, defined with a term prehabilitation, and their impact on a postoperative course of the patient. Three hundred seventy records were revealed and 13 studies were finally included in the analysis.
Results
According to qualified studies, prehabilitation improves significantly postoperative complications rate, length of hospital stay, postoperative physical activity, treatment costs, perioperative transfusions rate, antibiotic administration, and following the postoperative recommendations by patients. On the other hand, there is a lack of statistically significant impact of prehabilitation on quality of life, psychological condition, readmissions, and reoperations.
Discussion
Prehabilitation promotes development of multimodal care putting the patient’s well-being in the centre. Numerous studies indicate positive results of prehabilitation programs.
The final results depend on the protocol of prehabilitation, selected group of patients and standard of care of the center.
Conclusion
Prehabilitation is necessary for providing the highest quality of care for a surgical patient. Interdisciplinary approach benefit a patient during the operation as well as in the postoperative period. Every surgical clinic should be aware of the idea of prehabilitation and possibly create their own programs.
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Affiliation(s)
- Pamela Jeske
- Katedra i Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Uniwersytet Medyczny w Poznaniu
| | - Bartosz Wojtera
- Katedra i Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Uniwersytet Medyczny w Poznaniu
| | - Tomasz Banasiewicz
- Katedra i Klinika Chirurgii Ogólnej, Endokrynologicznej i Onkologii Gastroenterologicznej, Uniwersytet Medyczny w Poznaniu
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van Gestel T, Groen LCB, Puik JR, van Rooijen SJ, van der Zaag-Loonen HJ, Schoonmade LJ, Danjoux G, Daams F, Schreurs WH, Bruns ERJ. Fit4Surgery for cancer patients during covid-19 lockdown – A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:1189-1197. [PMID: 35183411 PMCID: PMC8828288 DOI: 10.1016/j.ejso.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 01/18/2022] [Accepted: 02/07/2022] [Indexed: 12/11/2022]
Affiliation(s)
- T van Gestel
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands.
| | - L C B Groen
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - J R Puik
- Department of Surgery, Amsterdam University Medical Center Location VU, Amsterdam, the Netherlands
| | - S J van Rooijen
- Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | | | - L J Schoonmade
- Medical Library, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - G Danjoux
- South Tees Hospitals NHS Foundation Trust, UK; Honorary Professor, Hull York Medical School and Teesside University, UK
| | - F Daams
- Department of Surgery, Amsterdam University Medical Center Location VU, Amsterdam, the Netherlands
| | - W H Schreurs
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - E R J Bruns
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
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Bojesen RD, Grube C, Buzquurz F, Miedzianogora REG, Eriksen JR, Gögenur I. OUP accepted manuscript. BJS Open 2022; 6:6593209. [PMID: 35639564 PMCID: PMC9154067 DOI: 10.1093/bjsopen/zrac029] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/19/2022] [Accepted: 02/13/2022] [Indexed: 12/02/2022] Open
Abstract
Background Low functional capacity, malnutrition, and anaemia are associated with an increased risk of complications after surgery. These high-risk indicators can be improved through preoperative interventions. The aim of the study was to examine the effect of screening for modifiable high-risk factors combined with targeted interventions on postoperative complications in patients undergoing colorectal cancer surgery. Methods A controlled before-and-after study was conducted including patients with colorectal cancer undergoing elective curative surgery between August 2015 and October 2018, in two institutions (intervention and control hospital). The intervention consisted of a screening for anaemia, low functional capacity, and nutritional status and their implementation (iron supplementation, prehabilitation, nutritional supplements, and consultation with a dietician), for a minimum of 4 weeks before surgery. The primary outcome was a composite measure consisting of unplanned admission to the intensive care unit, complications with Clavien–Dindo score of 3a or above, length of hospital stay less than 10 days, readmission, or death within 30 days during the postoperative course. Results A total of 1591 patients were included for analysis with 839 at the intervention hospital and 752 at the control hospital. In a difference-in-difference analysis, adjusted for age, sex, smoking, stage of disease, ASA score, surgical approach, and surgical procedure, the intervention was associated with a 10.9 per cent (95 per cent c.i. 2.1 to 19.7 per cent) absolute risk reduction of a complicated postoperative course, primarily due to a reduction in severe complications. Conclusion The combined intervention of screening and prehabilitation was associated with a decreased risk of a complicated course, primarily in a reduction of severe complications.
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Affiliation(s)
- Rasmus D. Bojesen
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
- Correspondence to: Rasmus D. Bojesen, Department of Surgery, Slagelse Hospital, Fælledvej 11, 4200 Slagelse, Denmark (e-mail: and )
| | - Camilla Grube
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Fatima Buzquurz
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Rebecca E. G. Miedzianogora
- Department of Surgery, Slagelse Hospital, Slagelse, Denmark
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
| | - Jens R. Eriksen
- Department of Surgery, Zealand University Hospital, Køge, Denmark
| | - Ismail Gögenur
- Center for Surgical Science, Zealand University Hospital, Køge, Denmark
- Department of Surgery, Zealand University Hospital, Køge, Denmark
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Srinivasaraghavan N, Das N, Balakrishnan K, Rajaram S. Effect of Whey Protein Supplementation on Perioperative Outcomes in Patients with Cancer-A Systematic Review and Meta-Analysis (PROSPERO 2020: CRD42020188666). Nutr Cancer 2021; 74:2351-2364. [PMID: 34961401 DOI: 10.1080/01635581.2021.2020302] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Whey protein has several biochemical characteristics which make it an ideal nutritional supplement in cancer. This meta-analysis aims to evaluate the effects of whey on perioperative outcomes in cancer. A systematic review was conducted as per the Preferred Reporting of Systematic Reviews and Meta-analysis (PRISMA) guidelines. The primary outcome was postoperative complications. Secondary outcomes included 6-minute walk test, length of stay (LOS), and thirty-day readmission. Of the ten trials, six supplemented whey to meet protein requirements of around 1.2 mg/kg/day, and four supplemented whey variably. A synthesis of ten trials with 643 patients showed significantly decreased postoperative complications in the whey supplemented (22%) group as compared to the control (32%) (OR 0.61, 95% CI 0.41-0.90; P = 0.01). Analysis of six trials showed that patients supplemented with whey had greater functional walking capacity before surgery (MD 23.76 meters, 95% CI 4.05-43.47; participants = 377; P = 0.02) and after 4 weeks of surgery (MD 45.76, 95% CI 14.19-77.33; participants = 366; P = 0.004). Thirty-day readmissions and LOS showed no differences. Risk of bias varied between the trials and evidence was moderate to low. Whey protein supplementation improved the perioperative functional capacity and significantly reduced postoperative complications in patients with cancer.
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Affiliation(s)
| | - Nairita Das
- Department of Anesthesiology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Kalpana Balakrishnan
- Department of Anesthesiology, Cancer Institute (WIA), Chennai, Tamil Nadu, India
| | - Swaminathan Rajaram
- Department of Biostatistics and Cancer Registry, Cancer Institute (WIA), Chennai, Tamil Nadu, India
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Heil TC, Melis RJF, Maas HAAM, van Munster BC, Olde Rikkert MGM, de Wilt JHW, Adang EMM. Technical efficiency evaluation of colorectal cancer care for older patients in Dutch hospitals. PLoS One 2021; 16:e0260870. [PMID: 34919552 PMCID: PMC8682881 DOI: 10.1371/journal.pone.0260870] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 10/24/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Preoperative colorectal cancer care pathways for older patients show considerable practice variation between Dutch hospitals due to differences in interpretation and implementation of guideline-based recommendations. This study aims to report this practice variation in preoperative care between Dutch hospitals in terms of technical efficiency and identifying associated factors. METHODS Data on preoperative involvement of geriatricians, physical therapists and dieticians and the clinicians' judgement on prehabilitation implementation were collected using quality indicators and questionnaires among colorectal cancer surgeons and specialized nurses. These data were combined with registry-based data on postoperative outcomes obtained from the Dutch Surgical Colorectal Audit for patients aged ≥75 years. A two-stage data envelopment analysis (DEA) approach was used to calculate bias-corrected DEA technical efficiency scores, reflecting the extent to which a hospital invests in multidisciplinary preoperative care (input) in relation to postoperative outcomes (output). In the second stage, hospital care characteristics were used in a bootstrap truncated regression to explain variations in measured efficiency scores. RESULTS Data of 25 Dutch hospitals were analyzed. There was relevant practice variation in bias-corrected technical efficiency scores (ranging from 0.416 to 0.968) regarding preoperative colorectal cancer surgery. The average efficiency score of hospitals was significantly different from the efficient frontier (p = <0.001). After case-mix correction, higher technical efficiency was associated with larger practice size (p = <0.001), surgery performed in a general hospital versus a university hospital (p = <0.001) and implementation of prehabilitation (p = <0.001). CONCLUSION This study showed considerable variation in technical efficiency of preoperative colorectal cancer care for older patients as provided by Dutch hospitals. In addition to higher technical efficiency in high-volume hospitals and general hospitals, offering a care pathway that includes prehabilitation was positively related to technical efficiency of hospitals offering colorectal cancer care.
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Affiliation(s)
- Thea C. Heil
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - René J. F. Melis
- Department of Geriatric Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Huub A. A. M. Maas
- Department of Geriatric Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Barbara C. van Munster
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | - Eddy M. M. Adang
- Department for Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands
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